Which nursing action would be appropriate to protect a patient during a seizure? (Select all that apply)
Placing a pad under the patient's head after guiding them to the floor from a standing position
Avoiding placing any objects in the mouth when the patient's teeth are clenched
Guiding the patient to the bed from the floor during a seizure
Turning the patient to one side, having a slightly forward-tilted head
Using supporting pillows for the patient who is on bed
Correct Answer : A,B,D,E
A. Placing a pad under the patient's head after guiding them to the floor from a standing position: This helps to protect the head from injury if the patient falls. However, guiding the patient to the floor should only be done if it is safe and possible to do so without causing further injury.
B. Avoiding placing any objects in the mouth when the patient's teeth are clenched: This prevents the risk of choking or damaging the patient's teeth. It is a common safety measure during seizures.
C. Guiding the patient to the bed from the floor during a seizure: This action is not appropriate during the seizure itself as it may cause injury or disrupt the patient's movement. Instead, the patient should remain in a safe position until the seizure ends.
D. Turning the patient to one side, having a slightly forward-tilted head: This helps to prevent aspiration and facilitates easier breathing during and after the seizure.
E. Using supporting pillows for the patient who is on bed: This helps to protect the patient from injury and provides support, ensuring safety during and after the seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Bronchial airway constriction: During the fight-or-flight response, bronchial airways typically dilate to increase airflow to the lungs, not constrict.
B. Hypoglycemia: The fight-or-flight response typically increases blood glucose levels to provide quick energy, leading to hyperglycemia rather than hypoglycemia.
C. Dilated pupils: Pupils dilate during the fight-or-flight response to enhance vision and perception of potential threats. This is a correct manifestation of the stress response.
D. Decreased blood pressure: The fight-or-flight response usually causes an increase in blood pressure due to the release of adrenaline and other stress hormones that prepare the body for immediate action.
Correct Answer is C
Explanation
A. Question-and-answer: This strategy involves the nurse asking questions to assess the client's understanding and provide information, but it does not involve the client performing the skill.
B. Role-play: Role-play involves the client acting out scenarios to practice skills, but this is not the method being described where the client is simply asked to perform a skill.
C. Return demonstration: This strategy involves the client performing a skill or procedure after being shown how to do it, allowing the nurse to assess the client's competence in the skill. This is the method being described in the scenario.
D. Discussion: Discussion involves talking through concepts or information but does not include the client actively performing a skill.
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