The client tells the nurse, "I am about to have a seizure." Which of the actions should the nurse implement? (Select all that apply)

Loosen the patient's clothing

Ease the patient to the floor if standing

Restrain the patient

Protect the patient's mouth with a padded tongue blade

Provide privacy

Answer and Explanation

Correct Answer : A,B,E

Choice A rationale:
Loosening the patient's clothing around the neck and chest promotes easier breathing during the seizure. It also prevents potential injury from constrictive clothing that could restrict movement or circulation.
Choice B rationale:
Easing the patient to the floor if they are standing helps to prevent falls and injuries that could occur due to loss of consciousness and muscle control during the seizure. It's crucial to guide the patient gently to the floor to avoid abrupt movements that could trigger or worsen the seizure.
Choice C rationale:
Restraining the patient during a seizure is not recommended as it can cause harm. Attempting to restrain a patient's movements during a seizure can lead to muscle strains, joint injuries, or even fractures. It can also increase anxiety and agitation, potentially prolonging the seizure.
Choice D rationale:
Protecting the patient's mouth with a padded tongue blade is not necessary and can even be dangerous. It was once a common practice, but it's now discouraged as it can cause oral injuries, obstruct the airway, or induce vomiting.

Choice E rationale:
Providing privacy helps to protect the patient's dignity and reduce any potential embarrassment during the seizure. It also creates a calmer and less stimulating environment, which can be beneficial in managing the seizure.

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Correct Answer is C

Explanation

Choice A rationale:
A high-purine diet is not recommended for clients with gout. Purines are substances found in certain foods, such as red meat, organ meats, seafood, and beer. When the body breaks down purines, it produces uric acid. Uric acid is a waste product that can build up in the blood and cause gout attacks.
Choice B rationale:
Aspirin is not typically recommended for clients with gout. In fact, aspirin can sometimes worsen gout symptoms by increasing uric acid levels in the blood.
Choice C rationale:
Limiting alcohol intake is a key part of the treatment regimen for gout. Alcohol can increase uric acid levels in the blood and trigger gout attacks.
Choice D rationale:
Limiting fluid intake is not recommended for clients with gout. In fact, it is important for clients with gout to stay well- hydrated to help flush uric acid out of the body.

A. Pitting edema of the hands and fingers B. Grey colored, non-purpuric papular rash C. Dry, red rash across the bridge of the nose and on the cheeks D. Subcutaneous nodules on the ulnar side of the arm

Correct Answer is C

Explanation

Choice A rationale:
Pitting edema of the hands and fingers is not a typical finding in SLE. It can occur in some cases, but it is more commonly associated with other conditions such as kidney disease or heart failure.

Choice B rationale:
Grey colored, non-purpuric papular rash is not a characteristic of SLE. This type of rash is more commonly seen in conditions such as lichen planus or sarcoidosis.

Choice C rationale:
A dry, red rash across the bridge of the nose and on the cheeks, also known as a malar rash, is a classic sign of SLE. It is often described as a "butterfly rash" because of its shape. The rash is caused by inflammation of the small blood vessels in the skin. It is typically worsened by sun exposure.

Choice D rationale:
Subcutaneous nodules on the ulnar side of the arm are a characteristic finding in rheumatoid arthritis, not SLE.

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The client tells the nurse, "I am about to have a seizure." Which of the actions should the nurse implement? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is C

Explanation

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