A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room?

Oral suction equipment

Tongue depressor

Tracheostomy tray

Wrist restraints

Answer and Explanation

The Correct Answer is A

A. Oral suction equipment is correct. During a seizure, there is a risk of aspiration due to the loss of airway control. Oral suction equipment should be readily available in the room to clear the airway if needed, especially if the client experiences a seizure with oral secretions.

B. Tongue depressor is incorrect. A tongue depressor should never be used during a seizure. Inserting a tongue depressor into the mouth can result in injury to both the client and the caregiver and should be avoided.

C. Tracheostomy tray is incorrect. While a tracheostomy tray might be necessary for clients with tracheostomies, it is not a standard requirement for clients on seizure precautions unless the client has specific respiratory concerns or requires a tracheostomy for airway management.

D. Wrist restraints is incorrect. Wrist restraints are not recommended during a seizure, as they can cause injury and impede movement. Instead, the goal is to provide a safe environment to prevent injury during a seizure.

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Correct Answer is A

Explanation

A. Chadwick's sign is correct. Chadwick's sign refers to a purplish or bluish discoloration of the vagina and vulva that occurs early in pregnancy due to increased blood flow to the pelvic area. This is typically seen around the 8th week of gestation.

B. Hegar's sign is incorrect. Hegar's sign refers to the softening of the lower uterine segment, which is a physical change that can be felt during a pelvic examination. It is a sign of pregnancy but does not involve discoloration of the vaginal area.

C. Chloasma is incorrect. Chloasma, also called the "mask of pregnancy," refers to hyperpigmentation on the face, typically over the cheeks and forehead, not the vagina or vulva.

D. Ballottement is incorrect. Ballottement refers to a physical finding during a pelvic exam in which the examiner can feel the fetus floating in the amniotic fluid, typically observed after 16 weeks of pregnancy. It is unrelated to changes in vaginal or vulvar color.

A. "Sit back down for a few minutes when this occurs." B. "Take a daily potassium supplement." C. "Restrict your daily fluid intake." D. "Discontinue this medication if this occurs again."

Correct Answer is A

Explanation

A. "Sit back down for a few minutes when this occurs.": This is correct. Lightheadedness upon standing is a common side effect of ACE inhibitors due to their blood pressure-lowering effect. The client should be advised to sit down to prevent falls and allow the body to adjust.

B. "Take a daily potassium supplement.": This is incorrect. ACE inhibitors can increase potassium levels, and taking a potassium supplement without a healthcare provider’s recommendation may lead to hyperkalemia, a dangerous condition.

C. "Restrict your daily fluid intake.": This is incorrect. Dehydration can exacerbate hypotension, so it is not recommended to restrict fluid intake without further instructions from the provider.

D. "Discontinue this medication if this occurs again.": This is incorrect. The client should not discontinue medication without first consulting their healthcare provider. The healthcare provider may adjust the dosage or provide alternative recommendations to manage the side effects.

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A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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