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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Assessing lung sounds is an important part of monitoring a patient’s respiratory status, but it may not be the most immediate action if the patient is finding it increasingly difficult to breathe.

Choice B rationale

While explaining the progression of the syndrome is important for patient education, it may not be the most immediate action if the patient is experiencing difficulty breathing.

Choice C rationale

Guillain-Barre syndrome can affect the muscles used for breathing, resulting in a weakened or paralyzed diaphragm, which can lead to an ineffective breathing pattern. Therefore, if a patient states that it is getting harder to take a deep breath, the nurse should call the physician and prepare for possible intubation.

Choice D rationale

Encouraging the client to cough may not be the most appropriate action if the patient is finding it increasingly difficult to breathe.

A. “I will need to take edrophonium to treat the disease.”. B. “This disease is a disorder of motor and sensory dysfunction.”. C. “This disease doesn’t cause sensory impairment.”. D. “I will continue to experience progressive muscle weakness and sensory deficits.”.

Correct Answer is A

Explanation

Choice A rationale
Myasthenia gravis is a neuromuscular disorder characterized by weakness and fatigue of voluntary muscles. Edrophonium is a medication that is used in the diagnosis and treatment of myasthenia gravis. It works by inhibiting the breakdown of acetylcholine, a neurotransmitter that transmits signals in the nervous system, thereby improving muscle strength.
Choice B rationale
Myasthenia gravis is not a disorder of motor and sensory dysfunction. It primarily affects the neuromuscular junction, leading to muscle weakness and fatigue. Sensory function is typically not affected in myasthenia gravis.
Choice C rationale
This statement is correct in that myasthenia gravis does not cause sensory impairment. However, it does not indicate an understanding of the disease as a whole, as it does not address the primary symptom of muscle weakness.
Choice D rationale
Myasthenia gravis does cause progressive muscle weakness, but it does not cause sensory deficits. Therefore, this statement indicates a partial understanding of the disease.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client recently diagnosed with Guillain-Barre syndrome. The client states, “It is getting harder to take a deep breath.”. Which action by the nurse is most appropriate?

Correct Answer is C

Explanation

A nurse is educating a client recently diagnosed with myasthenia gravis. Which statement made by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

The nurse is providing care for a patient in status epilepticus. What nursing intervention takes the highest priority?

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The nurse is caring for a client that has been diagnosed with aphasia. How can the nurse communicate effectively with the client?

In the context of an initial assessment for a client admitted to rule out Guillain-Barre syndrome, which of the following symptoms would the nurse expect to observe?

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The nurse is precepting a new nurse who is caring for a patient with a history of Huntington’s disease. The new nurse is preparing to feed the patient lunch. What action by the new nurse would cause the precepting nurse to intervene?

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.)