A client with a history of seizures is being admitted to the emergency room after experiencing a partial seizure. Which question would be most appropriate for the nurse to ask the client?
“Were you feeling jittery or irritable prior to the seizure?”
“Are you feeling sleepy or very tired at this time?”
“When did you last take your seizure medication?”
“Do you know if you lost consciousness during the seizure?”
The Correct Answer is C
Choice A rationale:
While inquiring about pre-seizure symptoms can be informative, it's not the most crucial question at this point. The priority is to gather information about medication adherence to assess potential causes for the breakthrough seizure.
Choice B rationale:
Assessing for post-ictal fatigue is important, but it's not the most pressing question in the immediate aftermath of a seizure. Determining medication adherence takes precedence.
Choice D rationale:
Establishing whether consciousness was lost can aid in classifying seizure type, but it's not as critical as understanding medication adherence in the initial assessment.
Choice C rationale:
This question directly addresses a potential cause of the seizure. Understanding when the client last took their medication can help determine if missed or delayed doses contributed to the seizure, guide medication adjustments, and inform further seizure prevention strategies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Restricting weight-bearing on the affected foot may provide some temporary relief from pain during an acute gout attack. However, it is not a long-term management strategy and can lead to muscle weakness and joint stiffness. It's important to gradually resume weight-bearing activities as tolerated to maintain joint function.
Choice B rationale:
Adequate fluid intake is essential for overall health and can help to flush out uric acid from the body. However, 8 liters per day is an excessive amount of fluid and could lead to electrolyte imbalances and other health problems. A more appropriate recommendation for a client with gout would be to aim for a fluid intake of 2-3 liters per day, unless otherwise advised by a healthcare provider.
Choice C rationale:
Restricting consumption of foods high in purines is a key management strategy for gout. Purines are substances found in certain foods that break down into uric acid in the body. High levels of uric acid can lead to the formation of urate crystals, which deposit in joints and cause inflammation and pain. Examples of foods high in purines include organ meats, red meat, seafood, and some types of beans and lentils.
Choice D rationale:
Calcium supplements have not been shown to be effective in the management of gout. In fact, some studies have suggested that calcium supplements may even increase the risk of gout attacks.
Correct Answer is D
Explanation
Choice A rationale:
The length of time the mother has been caring for the baby is not directly relevant to the risk of HIV transmission through breastfeeding. While a longer duration of breastfeeding may increase overall exposure, the primary concern is whether breastfeeding is occurring at all, as it presents a significant transmission route.
Choice B rationale:
Kissing does not typically transmit HIV, as the virus does not survive well outside the body. While there is a very low theoretical risk of transmission if both individuals have open sores or bleeding gums, it's not a primary concern in this scenario.
Choice C rationale:
The timing of the baby's last antibiotic treatment is not directly relevant to the risk of HIV transmission from breastfeeding. Antibiotics do not prevent or treat HIV infection, and their use would not impact the assessment of breastfeeding-related risks.
Choice D rationale:
Breastfeeding is a significant route of HIV transmission from mother to child. If the baby is breastfeeding, it's crucial for the nurse to determine the mother's viral load and CD4 count, assess the baby's HIV status, and provide appropriate counseling and interventions to reduce the risk of transmission. This information is essential for guiding decisions about infant feeding and potential prophylactic measures to protect the baby's health.
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