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 B

Explanation

Choice A rationale:
Acute retroviral syndrome (ARS) is an early stage of HIV infection that often presents with flu-like symptoms. It does not determine AIDS diagnosis.

Choice B rationale:
A CD4+ T lymphocyte level of less than 200 cells/mm is a defining criterion for AIDS diagnosis. This low count indicates a severely weakened immune system, leading to susceptibility to opportunistic infections and other AIDS-defining illnesses.

Choice C rationale:
A person with HIV can transmit the virus to others regardless of their CD4+ T cell count. Transmission risk is not a diagnostic criterion for AIDS.

Choice D rationale:
HIV-specific antibodies are produced by the immune system in response to HIV infection but their presence does not signify AIDS progression.

Correct Answer is ["8"]

Explanation

Step 1: Determine the desired dose in mL.

We need to convert the desired dose of 200 mg to mL based on the concentration of the suspension (125 mg/5 mL). We can achieve this using the following proportion:

Desired dose (mg) / Concentration (mg/mL) = Volume (mL) Step 2: Perform the calculation.

Substituting the known values:

200 mg / 125 mg/mL = Volume (mL) Solving for the volume:

Volume = 200 mg / 125 mg/mL

Volume ≈ 1.6 mL

Step 3: Round the answer to a whole number, considering clinical practice.

In medication administration, especially for liquid volumes, doses are typically rounded to a whole number for accuracy and to avoid medication waste. Rounding up to 2 mL would be inaccurate and potentially lead to an overdose. Therefore, we round down to the nearest whole number, which is 1 mL.

Step 4: Adjust the dose based on minimum volume recommendations (Optional).

Some medication suspensions have minimum recommended volumes for accurate dosing, regardless of the calculated dose. Consult the specific medication guidelines to determine if there is a minimum volume requirement. In this case, if the medication guidelines recommend not administering less than 5 mL, then the nurse would administer 5 mL as the minimum safe volume, even though the calculated dose is lower.

Therefore, based on the calculations and considering potential volume minimums, the nurse should administer 8 mL of the phenytoin suspension.

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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)

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Naxlex Comprehensive Predictor Exams

A client who abused intravenous drugs was diagnosed with the human Immunodeficiency virus (HIV) several years ago. The nurse explains that the diagnostic criterion for acquired immunodeficiency syndrome (AIDS) has been met when the client:

Correct Answer is B

Explanation

Phenytoin (Dilantin) suspension 200 mg is prescribed for a client with epilepsy.The suspension contains 125 mg/5 ml. How much solution should the nurse administer? Record your answer using a whole number.

Correct Answer is ["8"]

Explanation

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