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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Yoga is not the subject of this group": This response dismisses the client's curiosity and could shut down the conversation. Shutting down the discussion abruptly can make clients feel unheard and discourage participation, hindering the therapeutic environment.
B. "What do you want to know about it?": This response validates the client's interest and encourages open discussion. The nurse can provide a brief explanation without derailing the group session.
C. "Wait, let her finish talking": This response may seem dismissive and could discourage engagement. It is important to address the interruption respectfully while also encouraging dialogue.
D. "Do not interrupt in group again": This kind of response can create a hostile environment, shut down communication, and damage the therapeutic relationship between the nurse and the clients, especially in a mental health setting where trust and open expression are vital.
Correct Answer is B
Explanation
A. Report any increase in the white blood cell count: While monitoring for signs of infection is important, an increase in WBC count alone does not address the risk of MRSA recurrence in the wound. Early intervention with infection control measures is more important.
B. Change the surgical dressing readily when soiled: A soiled dressing acts as a wick, pulling moisture and bacteria toward the incision. In a postoperative client with a history of MRSA, any drainage or moisture trapped against the skin provides a medium for the staphylococcus bacteria to multiply and invade the surgical site. Changing the dressing readily when soiled ensures that the wound environment remains unfavorable for bacterial growth, directly reducing the risk of a localized recurrence or surgical site infection (SSI).
C. Instruct the family to adhere to contact precautions: Instructing the family on contact precautions is essential for preventing the spread of MRSA to others (the nurse, other patients, or the family members themselves), but it does not directly reduce the risk of the client's own MRSA recurring in their new surgical wound.
D. Wear a face mask while performing wound care: Wearing a face mask is not necessary for preventing MRSA transmission in the wound care setting. Contact precautions, including proper hand hygiene and wearing gloves, are more effective for MRSA prevention.
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