A nurse is reinforcing discharge teaching to a client who has epilepsy. Which of the following instructions should be included in the teaching?
Placing padding around or under the patient's head
Positioning the patient on the side once the relaxation stage is entered to allow oral secretions to drain
Have the necessary equipment and/or personnel in case the patient doesn't spontaneously breath when the seizure is over
Insert a tongue depressor in the patient's mouth
Note the time the seizure started
Hold the patient down to prevent injury
Correct Answer : A,B,C,E
A. Placing padding around or under the patient's head
This is a helpful instruction to include. Placing padding around or under the patient's head can help prevent injury during a seizure by cushioning the head against impact with the ground.
B. Positioning the patient on the side once the relaxation stage is entered to allow oral secretions to drain
This is a correct instruction. Positioning the patient on their side (recovery position) can help prevent aspiration if vomiting occurs during or after the seizure. It also helps clear oral secretions and maintain a clear airway.
C. Having the necessary equipment and/or personnel in case the patient doesn't spontaneously breathe when the seizure is over
This is an important instruction. It is crucial to have emergency equipment (such as oxygen and suction) readily available and to be prepared to provide respiratory support if the patient does not spontaneously breathe after the seizure.
D. Inserting a tongue depressor in the patient's mouth
This is an incorrect instruction. It is not recommended to insert anything into the patient's mouth during a seizure as it can cause injury to the teeth, gums, or airway. Additionally, it is a common misconception that tongue swallowing occurs during seizures, which is rare.
E. Noting the time the seizure started
This is a critical instruction. Noting the time the seizure started helps healthcare providers assess the duration of the seizure and determine if medical intervention is necessary. It also helps monitor the patient's recovery and response to treatment.
F. Holding the patient down to prevent injury
This is an incorrect instruction. Holding the patient down during a seizure can cause injury to both the patient and the person restraining them. It is important to create a safe environment by removing hazards and guiding the patient away from dangerous objects or situations, but holding them down is not appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The client should maintain systolic BP between 120 and 129 mm Hg.
This is an appropriate recommendation. The American Heart Association (AHA) guidelines recommend maintaining systolic BP below 130 mm Hg to reduce the risk of stroke and other cardiovascular events in individuals with a history of stroke or TIA.
B. The client should maintain systolic BP between 130 and 135 mm Hg.
This is slightly above the recommended range. While systolic BP below 135 mm Hg is generally recommended for individuals with a history of stroke or TIA, a range of 130-135 mm Hg may still be acceptable based on individual patient factors and risk assessments.
C. The client should maintain systolic BP between 136 and 140 mm Hg.
This is above the recommended range. Systolic BP between 136 and 140 mm Hg may be considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.
D. The client should maintain systolic BP between 141 and 145 mm Hg.
This is above the recommended range. Systolic BP above 140 mm Hg is generally considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.
Correct Answer is C
Explanation
A. Increased blinking
Increased blinking is not a typical manifestation of bradykinesia. In fact, individuals with Parkinson's disease may experience reduced blinking (hypokinesia of blinking) rather than increased blinking.
B. States of euphoria
Euphoria is not typically associated with bradykinesia. Instead, individuals with Parkinson's disease may experience a range of mood changes, including depression, anxiety, or apathy, but euphoria is not a common finding.
C. Slurred speech
This is the correct answer. Slurred speech, or dysarthria, can occur in individuals with Parkinson's disease as a result of bradykinesia affecting the muscles involved in speech production. Bradykinesia can cause a reduction in the speed and coordination of movements necessary for clear speech, resulting in slurred or mumbled speech patterns.
D. Decreased respiratory rate
Decreased respiratory rate is not typically associated with bradykinesia. Bradykinesia primarily affects voluntary movements rather than involuntary processes such as respiration. While respiratory muscle weakness can occur in advanced stages of Parkinson's disease, it is not directly related to bradykinesia.
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