While at the urgent care clinic for a routine physical exam, a 27-year-old man experiences a tonic-clonic seizure. While awaiting emergency medical services response, the NP will avoid which of the following interventions?
Rolling the patient over to the recovery position
Restraining the patient
Maintaining the patient's airway
Obtaining IV access, if possible
The Correct Answer is B
Choice A reason: Rolling the patient into the recovery position is an essential intervention during a seizure. This helps maintain an open airway and prevents aspiration if the patient vomits. It is a safe and recommended practice to protect the patient without causing harm.
Choice B reason: Restraining a patient during a tonic-clonic seizure can cause injury to both the patient and the healthcare provider. It is contraindicated because it can lead to broken bones, joint dislocations, and soft tissue injuries. The safest approach is to ensure the area around the patient is clear and allow the seizure to run its course while maintaining airway and safety.
Choice C reason: Maintaining the patient’s airway is critical during a seizure to prevent hypoxia and aspiration. Interventions can include positioning the patient on their side, suctioning secretions if necessary, and monitoring for respiratory compromise. This is a recommended and life-saving action.
Choice D reason: Obtaining IV access, if possible, is important for rapid administration of emergency medications if the seizure is prolonged or complications arise. While not immediately necessary during the seizure onset, it is appropriate to prepare for potential interventions safely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Guided imagery is a mind-body technique that involves visualization and mental imagery, not direct manipulation of the body.
Choice B reason: Meditation is a mental practice focusing on mindfulness and relaxation, not considered manipulative or body-based.
Choice C reason: Reflexology involves applying pressure to specific points on the hands, feet, or ears to stimulate corresponding areas of the body, making it a manipulative body-based therapy.
Choice D reason: Yoga combines movement, stretching, and mindfulness; although physical, it is not primarily manipulative in the therapeutic sense.
Correct Answer is B
Explanation
Choice A reason: Severe dehydration can cause dizziness and weakness, but the presence of confusion and nausea in a type 1 diabetic patient raises concern for metabolic disturbance rather than isolated dehydration.
Choice B reason: Diabetic ketoacidosis (DKA) is characterized by hyperglycemia, ketonemia, dehydration, nausea, vomiting, weakness, and altered mental status. Patients with type 1 diabetes, particularly those with eating disorders, are at increased risk due to insulin omission or inadequate intake.
Choice C reason: Acute renal failure can present with nausea, confusion, and weakness, but there is no information suggesting a sudden change in kidney function or laboratory evidence in this scenario.
Choice D reason: Myocardial toxicity is unlikely in this presentation; while electrolyte disturbances may affect the heart, the immediate constellation of symptoms in a type 1 diabetic points more toward DKA.
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