The nurse is teaching a client's family member about seizure precautions. Which action described by the family member indicates the need for additional teaching?

Avoid forcing apart the teeth.

Loosen clothing around the neck.

Position the head from injury.

Secure the limbs to the body.

Answer and Explanation

The Correct Answer is D

A. Avoid forcing apart the teeth: Placing objects in the client’s mouth or trying to pry open the teeth can cause injury. It is important to let the seizure pass without interfering with the jaw or mouth.

B. Loosen clothing around the neck: Loosening tight clothing reduces the risk of airway obstruction or restricted breathing during a seizure. This is a correct and helpful intervention.

C. Position the head from injury: Protecting the client’s head with a soft object prevents trauma during convulsions. This is a recommended and safe practice during seizures.

D. Secure the limbs to the body: Restraining or holding down limbs can cause musculoskeletal injuries and increase agitation. Seizure safety protocols emphasize allowing movement without physical restraint.

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Correct Answer is A

Explanation

A. Chest tube insertion tray: Thoracentesis may lead to complications like pneumothorax, especially in clients with lung disease such as emphysema. If air or fluid reaccumulates or lung collapse occurs, a chest tube may be urgently required to re-expand the lung and drain air or fluid buildup.

B. Intubation tray: While intubation may be needed in cases of severe respiratory failure, it is not the first-line equipment after an ineffective thoracentesis. It would only be used if the patient is unable to breathe adequately despite other interventions.

C. Ventilator: Mechanical ventilation is not immediately needed for a failed thoracentesis unless the client develops respiratory failure. It is a secondary measure if oxygenation cannot be maintained with basic support.

D. Crash cart: A crash cart is essential during cardiac arrest or life-threatening emergencies. It is not the most appropriate equipment to have specifically for an ineffective thoracentesis unless severe complications arise suddenly.

A. Electromyography. B. Skin biopsy. C. Complete blood count. D. Allergy test.

Correct Answer is C

Explanation

A. Electromyography: Electromyography assesses electrical activity in muscles and is used to diagnose neuromuscular disorders. It is not relevant to evaluating bleeding tendencies or pinpoint skin spots, which suggest a hematologic issue like thrombocytopenia.

B. Skin biopsy: A skin biopsy might help diagnose dermatologic conditions, but it is invasive and not the initial step when systemic drug side effects like petechiae are suspected. The presence of red spots suggests a possible blood disorder requiring laboratory confirmation first.

C. Complete blood count: A CBC is essential to evaluate for thrombocytopenia, a known adverse effect of zidovudine. Pinpoint red spots, or petechiae, are often linked to low platelet counts, which require prompt detection and management to prevent serious complications.

D. Allergy test: Allergy testing identifies hypersensitivity reactions, typically associated with rashes or itching. Petechiae are not commonly caused by allergic reactions but are more indicative of blood abnormalities, making this test less immediately relevant.

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The nurse is teaching a client's family member about seizure precautions. Which action described by the family member indicates the need for additional teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is C

Explanation

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