A client that the nurse is caring for experiences a seizure. What would be a priority nursing action?

Restrain the client during the seizure.

Protect the client from injury.

Suction the mouth during the convulsion.

Insert a tongue blade between the teeth.

Answer and Explanation

The Correct Answer is B

During a seizure, the nurse's priority is to ensure the client's safety by protecting them from injury. The nurse should loosen any tight clothing and move furniture or objects that may harm the client. The client should be turned onto their side to prevent aspiration, and suctioning the mouth is not indicated during the seizure. Restraints are not appropriate during a seizure, and inserting a tongue blade between the teeth can cause injury.

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Correct Answer is B

Explanation

Inspection, followed by Auscultation, Percussion, and Palpation. Inspection assesses for abdominal contour, symmetry, any visible masses, scars or other abnormalities. Auscultation assesses bowel sounds, and Percussion assesses for any areas of tenderness, and to determine the presence of fluid, gas or masses. Palpation assesses for any masses, areas of tenderness, organ size or other abnormalities. This is the order that allows the nurse to assess the abdomen systematically and accurately.

A: Palpation comes last because it can stimulate bowel sounds, which can make the nurse miss some of the sounds while auscultating.

C: Auscultation must be done before percussion and palpation to prevent altering bowel sounds.

D: Percussion comes before palpation to avoid altering the underlying structures of the abdomen.

A. Fluid accumulation under the arm. B. Drainage from the area. C. Reddened area around the breast. D. Enlargement of the arm or hand.

Correct Answer is A

Explanation

Fluid accumulation under the arm. The presence of fluid accumulation (edema) under the arm may indicate the spread of breast cancer to the lymph nodes. The physician should be notified, and further evaluation and treatment may be necessary.

Option B: Drainage from the area is not a correct answer as it may indicate a surgical site infection or an abscess, but not necessarily the spread of cancer.

Option C: Reddened area around the breast is not a correct answer as it may indicate a skin infection or inflammation, but not necessarily the spread of cancer.

Option D: Enlargement of the arm or hand is not a correct answer as it may indicate lymphedema, which is a swelling due to lymphatic system damage, but not necessarily the spread of cancer.

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A client that the nurse is caring for experiences a seizure. What would be a priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? (Use all options.)

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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