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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["033"]
Explanation
Step 1 is to calculate the number of milliliters (mL) that contain the ordered dose of 300 mg of clindamycin.
Step 2 is to divide the total milliliters (mL) from Step 1 by the infusion time in minutes to get the flow rate in mL/hour. Here are the calculations:
Step 1:
900 mg of clindamycin is in 50 mL.
To find the mL that contain 300 mg, set up a proportion:
(300 mg / 900 mg) = (x mL / 50 mL) Cross-multiply and solve for x:
x = (300 mg * 50 mL) / 900 mg x = 16.67 mL
Step 2:
The infusion time is 30 minutes.
Divide the total mL (16.67 mL) by the infusion time in hours to get the flow rate in mL/hour: Flow rate = 16.67 mL / (30 minutes / 60 minutes/hour)
Flow rate = 33.33 mL/hour
Round to the nearest whole number, using a leading zero if it applies, and no trailing zero: Flow rate = 033 mL/hour
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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