A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?

Presence of absence seizures

Postictal phase

Presence of automatisms

Aura phase

Answer and Explanation

The Correct Answer is B

The nurse should use the term "postictal phase" when documenting the client's difficulty arousing and sleepiness for several hours following a generalized tonic-clonic seizure. The postictal phase is the period of time immediately following a seizure during which the client may be difficult to arouse and very sleepy.

Presence of absence seizures, presence of automatisms, and aura phase are not appropriate descriptions for the nurse to use when documenting this finding in the medical record. Absence seizures are a type of seizure characterized by brief episodes of staring and unresponsiveness. Automatisms are repetitive, unconscious movements that can occur during a seizure. The aura phase is a warning sign that can occur before a seizure.

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Correct Answer is B

Explanation

The knee is a hinge type of joint. When describing range-of-motion exercises, the nurse should explain that the knee is a hinge joint. A hinge joint is a type of synovial joint that mainly allows for ﬂexion and extension (and a small degree of medial and lateral rotation)¹. The knee joint is formed by articulations between the patella, femur, and tibia.

a. The knee is not a pivot joint.
c. The knee is not a ball and socket joint.
d. The knee is not a gliding joint.

A. Remain with the client and call for help. B. Place the client in the lateral position C. Reorient and reassure the client. D. Check the client for injuries.

Correct Answer is A,B,D,C

Explanation

The correct sequence of steps the nurse should follow when a client begins to experience a tonic-clonic seizure is:

Remain with the client and call for help.
Place the client in the lateral position.
Check the client for injuries.
Reorient and reassure the client.

The nurse should first remain with the client and call for help to ensure that additional assistance is on the way. Next, the nurse should place the client in the lateral position to help keep their airway open and prevent aspiration. After the seizure has ended, the nurse should check the client for injuries that may have occurred during the seizure. Finally, the nurse should reorient and reassure the client, who may be confused or disoriented after the seizure.

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A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has a knee injury. When describing range-of-motion exercises, the nurse should explain that the knee is which of the following types of joints?

Correct Answer is B

Explanation

Correct Answer is A,B,D,C

Explanation

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