A male client with a brain tumor is scheduled for a biopsy in the morning. During the admission procedure, the client has a tonic-clonic seizure that lasts 50 seconds. Following the seizure, the client is lethargic and confused and his wife tells the nurse that her husband has never had a seizure before and has always been alert and communicative. Which action should the nurse take?
Notify the emergency response team of the client's seizure.
Keep orienting the client to time and place until he is less confused.
Explain the postictal state that usually follows seizures.
Ask the wife to wait outside the room until the nurse can talk with her.
The Correct Answer is B
Choice A: Notifying the emergency response team of the client's seizure is not a necessary action for the nurse, as the seizure has already stopped and there is no immediate threat to the client's life. This is a distractor choice.
Choice B: Keeping orienting the client to time and place until he is less confused is an appropriate action for the nurse, as this can help restore the client's cognitive function and reduce his anxiety after a seizure. Therefore, this is the correct choice.
Choice C: Explaining the postictal state that usually follows seizures is not a priority action for the nurse, as this can be done later when the client is more alert and receptive. This is another distractor choice.
Choice D: Asking the wife to wait outside the room until the nurse can talk with her is not a considerate action for the nurse, as this can increase her stress and worry about her husband's condition. This is a contraindicated choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice B reason: Forcing oral fluids and providing frequent small meals are not the most important interventions for a client with alcohol withdrawal delirium. Although hydration and nutrition are important to prevent dehydration and electrolyte imbalance, they are not the priority in this case. The client may have difficulty swallowing, vomiting, or aspiration due to altered mental status.
Choice C reason: Confronting the client's denial of substance abuse is not an appropriate intervention for a client with alcohol withdrawal delirium. The client may not be able to comprehend or respond rationally to such confrontation due to impaired cognition and perception. The nurse should avoid arguing or challenging the client's beliefs and focus on providing safety and comfort.
Choice D reason: Encouraging attendance and group participation is not a feasible intervention for a client with alcohol withdrawal delirium. The client may not be able to participate in any social or educational activities due to severe withdrawal symptoms and delusions. The nurse should limit visitors and stimuli and provide one-to-one supervision and reassurance.
Correct Answer is C
Explanation
Choice A reason: Increasing the intake of dark green leafy vegetables while taking warfarin is not a good instruction because it can decrease the effectiveness of warfarin. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin.
Choice B reason: Eating two servings of dark green leafy vegetables daily and continuing for 30 days after warfarin therapy is completed is not a good instruction because it can cause bleeding complications. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin. Stopping warfarin while continuing to eat high amounts of vitamin K can increase the risk of clot formation and thromboembolism.
Choice D reason: Avoiding eating any foods that contain any vitamin K because it is an antagonist of warfarin is not a good instruction because it can cause bleeding complications. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin. Eliminating vitamin K from the diet can increase the sensitivity to warfarin and cause excessive bleeding and bruising.
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