While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state?

Confusion

Body rigidity

Epileptic cry

Urinary incontinence

Answer and Explanation

The Correct Answer is A

A. Confusion: Confusion is a hallmark feature of the postictal state, occurring after a seizure as the brain recovers. Clients often experience disorientation, memory loss, and difficulty responding appropriately during this phase, which can last from minutes to hours.

B. Body rigidity: Body rigidity typically occurs during the tonic phase of a seizure, not in the postictal state. After the seizure ends, muscle tone usually relaxes, and rigidity subsides.

C. Epileptic cry: The epileptic cry happens at the onset of a tonic-clonic seizure due to sudden forced expiration against a closed glottis. It is not a characteristic of the postictal phase.

D. Urinary incontinence: Urinary incontinence can occur during a seizure due to loss of bladder control but is not a defining feature of the postictal state, which focuses on neurological recovery and altered consciousness.

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Correct Answer is C

Explanation

A. refuses to leave home to see a provider: Avoidance or refusal to leave home can be related to anxiety or depression but does not indicate confabulation. It reflects a behavioral response rather than a memory distortion.

B. displays compulsive and ritualistic behaviors: Compulsive or ritualistic behaviors are often seen in obsessive-compulsive disorders or some dementia types but are not examples of confabulation, which involves fabricating memories.

C. makes up stories when he is unable to remember actual events: Confabulation occurs when a client unintentionally creates fabricated or distorted memories to fill gaps caused by memory loss. This behavior is a common coping mechanism in dementia to mask cognitive deficits.

D. reminisces about the past: Reminiscing is recalling real past events and can be a positive activity for clients with dementia. It differs from confabulation, which involves inventing false memories.

Correct Answer is ["10"]

Explanation

Calculation:

Prescribed dose = 25 mg

Available concentration = 12.5 mg / 5 mL

Calculate the volume to administer.

Volume (mL) = (Prescribed dose / Available concentration) × Volume in concentration

= (25 mg / 12.5 mg) × 5 mL

= 2 × 5 mL

= 10 mL

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While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize confabulation when the client

Correct Answer is C

Explanation

Correct Answer is ["10"]

Explanation

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