A nurse is reinforcing teaching about seizure management with the family of a client who has a seizure disorder. Which of the following statements by a family member indicates an understanding of the teaching?
"I will gently restrain him during seizures."
"I will loosen his clothing during seizures."
"I will insert a washcloth in his mouth during seizures."
"I will turn him on his back during seizures."
The Correct Answer is B
A. "I will gently restrain him during seizures."- Restraint during seizures can cause injury and is not recommended.
B. "I will loosen his clothing during seizures."- Loosening tight clothing helps prevent injury and ensures adequate ventilation during a seizure.
C. "I will insert a washcloth in his mouth during seizures."- Inserting objects into the mouth during a seizure can cause injury or obstruct the airway.
D. "I will turn him on his back during seizures."- Placing the client on their back during a seizure can increase the risk of aspiration. The recovery position is preferred
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Verifying the bilirubin level of the tube contents is not a reliable method for confirming tube placement and may not provide accurate information.
B. Auscultating for air insufflation can help detect tube placement in the respiratory tract but may not reliably confirm placement in the gastrointestinal tract.
C. Requesting a chest x-ray is the most reliable method for confirming the placement of a feeding tube, as it allows visualization of the tube's position relative to anatomical landmarks.
D. Checking the pH level of gastric contents can help differentiate between gastric and respiratory placement but may not provide definitive confirmation of tube placement.
Correct Answer is B
Explanation
A. The nurse should stand on the client’s weaker side (left side) to provide support and stability during the transfer. Standing on the stronger side offers less assistance and increases the risk of falls.
B. When assisting a client with left-sided weakness to transfer from bed to chair, the nurse should use proper body mechanics to protect both the client and self.Flexing the hips and knees allows the nurse to use the leg muscles (strongest muscles) rather than the back, reducing risk of injury. This position also provides stability and balance, allowing controlled movement as the client stands.
C. Raise the bed to waist level before moving the client- Adjusting the bed height can facilitate the transfer process, but it is not directly related to the client's left-sided weakness.
D. Pivot on the foot farthest from the bed when assisting the client into the chair- Pivoting on the foot farthest from the bed allows for a smooth and controlled transfer motion but does not address the client's left-sided weakness specifically.
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