A nurse is caring for a client following a seizure. Which of the following actions should the nurse take?

Apply restraints if the client is agitated.

Ambulate the client.

Position the client on their side.

Raise all of the side rails on the client's bed.

Answer and Explanation

The Correct Answer is C

A. Apply restraints if the client is agitated. Restraints are not necessary and may increase distress. Post-seizure agitation should be managed with reassurance and monitoring.
B. Ambulate the client. This is unsafe because the client may be disoriented or weak, increasing the risk of falls. Rest and recovery should be prioritized.
C. Position the client on their side. This helps maintain an open airway, prevents aspiration, and facilitates secretion drainage, making it the priority intervention.
D. Raise all of the side rails on the client's bed. Raising all four side rails is considered a restraint. A safer environment should be maintained without unnecessary restriction.

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Correct Answer is A

Explanation

A. Reminding the AP about confidentiality is the appropriate immediate response. The nurse should provide education and reinforce HIPAA regulations to prevent future breaches.
B. Notifying the client is unnecessary and could cause undue distress. The priority is to address the behavior and prevent further violations.
C. Notifying the ethics committee is excessive for a first-time or minor violation. This step may be necessary if breaches continue despite education.
D. Filing an incident report is not required unless the breach has significant consequences. The best first step is direct education.

A. Rotavirus B. Human papillomavirus (HPV) C. Herpes zoster D. Diphtheria, tetanus, and acellular pertussis (DTaP)

Correct Answer is C

Explanation

A. Rotavirus vaccine is for infants, not older adults. It is given to prevent severe diarrhea caused by rotavirus.
B. Human papillomavirus (HPV) vaccine is recommended for adolescents and young adults, typically before age 26, to prevent cervical and other cancers.
C. Herpes zoster (shingles) vaccine is recommended for older adults, usually starting at age 50 or 60, to reduce the risk of shingles and its complications.
D. DTaP is given to infants and young children. Instead, older adults should receive a Td or Tdap booster every 10 years.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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