While waiting for an appointment in the doctor’s office, a patient experiences a convulsive seizure. The nurse is immediately notified.
What nursing care should be provided at this time? (Select all that apply.)
Open the patient’s jaw and insert a mouth gag
Move furniture away from the patient
Loosen constrictive clothing
Provide privacy
Restrain the patient to avoid self-injury
Position the patient on their side with their head flexed forward
Correct Answer : B,C,D,F
Choice A rationale
It is a common misconception that something should be placed in the mouth of someone having a seizure to prevent them from biting their tongue. However, this can cause more harm than good, including injury to the person’s mouth or the rescuer’s fingers.
Choice B rationale
Moving furniture away from the person having a seizure can help prevent injury. During a seizure, a person may move uncontrollably, and removing nearby objects can reduce the risk of harm.
Choice C rationale
Loosening constrictive clothing can help the person breathe more easily during and after a seizure.
Choice D rationale
Providing privacy can help maintain the person’s dignity and reduce embarrassment after a seizure.
Choice E rationale
It is not recommended to restrain a person during a seizure. This can result in injury. Instead, the goal is to keep the person safe until the seizure stops on its own.
Choice F rationale
Positioning the person on their side with their head flexed forward can help prevent aspiration, which can occur if the person vomits during or after a seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Supporting the right arm with a sling or pillow can help prevent shoulder dislocation, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice B rationale
While it is true that a patient who has experienced a stroke in the right hemisphere of the brain may exhibit some degree of expressive or receptive aphasia, anticipating this does not directly ensure the patient’s safety.
Choice C rationale
Placing the wheelchair on the client’s left side when transferring him into a wheelchair is a good practice, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice D rationale
Patients who have experienced a stroke in the right hemisphere of the brain often exhibit impulsiveness and poor judgment. Therefore, providing close supervision can help ensure the patient’s safety.
Correct Answer is B
Explanation
Choice B rationale
Patients who experience severe cluster headaches should be instructed to take medications as soon as they sense the onset of symptoms. Cluster headaches are characterized by severe, debilitating pain that reaches peak intensity within a short period of time, often within 15 minutes. Therefore, early intervention is crucial to manage the pain effectively.
Choice A rationale
Waiting twenty to thirty minutes after the onset of symptoms to take medications may not be effective for cluster headaches. The pain of a cluster headache often reaches peak intensity within 15 minutes, so delaying medication could result in unnecessary suffering.
Choice C rationale
Waiting until the patient’s pain becomes unbearable is not recommended for managing cluster headaches. The goal of treatment is to prevent or reduce pain, not to wait until it becomes unbearable.
Choice D rationale
Taking medications when the patient senses their symptoms are peaking is not the most effective strategy for managing cluster headaches. Given the rapid onset and severe pain associated with cluster headaches, medications should be taken as soon as the patient senses the onset of symptoms.
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