While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

Observe for prolonged periods of apnea.

Observe for lacerations to the tongue.

Document details of the seizure activity.

Evaluate for evidence of incontinence.

Answer and Explanation

The Correct Answer is A

A.   This intervention is important for assessing the client's respiratory status during and after the seizure. Apnea can cause cardiac arrest and respiratory failure and hence a priority.
B.   This intervention is crucial for assessing potential injury to the client's mouth or tongue, which can occur during a seizure due to involuntary muscle movements. However, before assessing for lacerations, the nurse should prioritize ensuring the client's safety.
C.   Documenting details of the seizure activity is important for maintaining accurate medical records and providing information to the healthcare team. However, before documenting details of the seizure, the nurse should prioritize ensuring the client's safety and providing immediate assistance during the seizure. Therefore, while documentation is essential, it may not be the first intervention to implement.
D.   While evaluating for incontinence is important for addressing the client's immediate needs and ensuring comfort, it may not be the first intervention to implement. The nurse should prioritize ensuring the client's safety and providing immediate assistance during the seizure.

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Correct Answer is C

Explanation

C. The DASH eating plan emphasizes consumption of fruits, vegetables, low-fat dairy products, whole grains, lean proteins, and limited amounts of saturated fats, cholesterol, and sodium. Therefore, enjoying fat-free yogurt as an occasional snack food aligns with the principles of the DASH eating plan.

A. is a good practice for food safety but does not specifically indicate adherence to the DASH eating plan. The DASH plan encourages consumption of fruits and vegetables but does not require meticulous cleaning or peeling.
B. may be suitable for individuals with lactose intolerance but is not a specific requirement of the DASH eating plan. The DASH plan recommends low-fat or fat-free dairy products but does not specify lactose-free products.
D. The DASH plan encourages consumption of whole grains as part of a balanced diet and recommends incorporating whole grains such as whole wheat, brown rice, and oats.

A. Exhibits angry outbursts when the subject of dying is approached. B. Increased intervals of sleep 18 out of 24 hours. C. A change has recently occurred in handwriting. D. Refuses to see friends or to return their phone calls.

Correct Answer is C

Explanation

C. One of the hallmark features of ADC is the development of cognitive impairment, including changes in memory, concentration, and problem-solving abilities. The change in handwriting (graphomotor impairment) is a specific neurological symptom that may indicate cognitive dysfunction and is consistent with the diagnosis of AIDS dementia.
A. This symptom suggests emotional distress or mood disturbances, which can occur in individuals with HIV/AIDS due to the psychological impact of the diagnosis and the uncertainty surrounding the disease progression. However, it is not specific to AIDS dementia
B. Increased sleepiness or hypersomnia can occur in individuals with AIDS dementia due to disruptions in sleep-wake cycles and alterations in brain function. However, increased sleepiness alone is not specific to AIDS dementia
D. Social withdrawal or isolation can occur in individuals with HIV/AIDS due to various reasons, including stigma, depression, or physical symptoms. However, it is not specific to AIDS dementia.

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While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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