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 A
Explanation
Choice A rationale:
Serum creatinine is a waste product that is produced by muscle metabolism and is normally excreted by the kidneys.
When kidney function is impaired, creatinine levels in the blood increase, making it a sensitive and specific indicator of renal function.
It is considered one of the most reliable markers for assessing kidney function and is routinely used to screen for and monitor kidney disease.
Choice B rationale:
Serum sodium is an electrolyte that is regulated by the kidneys, but it is not a direct measure of renal function. Sodium levels can be affected by various factors, including fluid intake, medications, and hormonal imbalances.
While abnormal sodium levels can sometimes be a sign of kidney dysfunction, they can also occur due to other conditions, making it less specific as an indicator of renal function.
Choice C rationale:
Blood urea nitrogen (BUN) is another waste product that is produced by the breakdown of proteins and is normally excreted by the kidneys.
However, BUN levels can be influenced by factors other than kidney function, such as dietary protein intake, dehydration, and gastrointestinal bleeding.
This makes BUN less specific than serum creatinine as a marker of renal function.
Choice D rationale:
Urine-specific gravity measures the concentration of solutes in urine, which can provide some information about kidney function.
However, it is not as sensitive or specific as serum creatinine.
Urine-specific gravity can be affected by factors such as fluid intake and hydration status, which can make it less reliable as an indicator of renal function.
Correct Answer is C
Explanation
Choice A rationale:
A high-purine diet is actually contraindicated in gout because purines are metabolized into uric acid, which can accumulate in the joints and trigger gout attacks. Therefore, a low-purine diet is recommended.
Choice B rationale:
Aspirin is not typically recommended for gout because it can interfere with the excretion of uric acid and potentially worsen the condition. While low-dose aspirin might be used for specific cardiovascular benefits in some gout patients, it's not a general treatment for gout itself.
Choice C rationale:Alcohol intake is a common trigger for gout attacks because it can increase uric acid levels in the blood. Therefore, limiting alcohol intake is an important part of managing gout.
Choice D rationale:
Fluid intake should be increased, not limited, in gout patients. This is because adequate hydration helps to flush uric acid out of the body and reduce the risk of gout attacks.
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