A nurse on a medical-surgical unit is checking the bowel sounds of a client who has epilepsy.
The client begins to experience a tonic-clonic seizure.
Identify the sequence of steps the nurse should follow.
(Move the steps into the box on the right, placing them in the selected order of performance.
Use all the steps.).
Reorient and reassure the client.
Remain with the client and call for help.
Check the client for injuries.
Place the client in the lateral position.
The Correct Answer is B
Step 1 is B. Remain with the client and call for help. This ensures the client’s safety and gets additional assistance. Step 2 is D. Place the client in the lateral position. This prevents aspiration if the client vomits. Step 3 is C. Check the client for injuries. After the seizure has ended, the nurse should assess for any injuries that may have occurred during the seizure. Step 4 is A. Reorient and reassure the client. After a seizure, the client may be confused and scared. Reorienting and reassuring the client can help them recover. So, the correct sequence is B, D, C,
A.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The client should indeed notify their provider before taking any other medications, as phenytoin can interact with many other drugs. This statement does not indicate a need for further teaching.
Choice B rationale:
Regular dental appointments are important as phenytoin can cause gum hyperplasia. This statement does not indicate a need for further teaching.
Choice C rationale:
This statement indicates a misunderstanding. Phenytoin is used to control seizures, not cure them. The client should not stop taking the medication when their seizures stop.
Choice D rationale:
Phenytoin can be taken with or without food, but it should be taken consistently in the same manner. This statement does not indicate a need for further teaching.
So, the correct answer is C, after analyzing all choices.
Correct Answer is A
Explanation
Choice A rationale:
Withholding the dose if having a fine hand tremor is not recommended. Hand tremors are a common side effect of lithium, but they can be managed by adjusting the dose.
Choice B rationale:
Avoiding foods with a high tyramine content is not necessary for lithium users. This dietary restriction is typically associated with certain antidepressants, not lithium.
Choice C rationale:
Limiting daily fluid intake is incorrect. Lithium can cause increased thirst and urination, so it’s important to maintain adequate hydration.
Choice D rationale:
Following a low-sodium diet is not advised. Both salt and fluid can affect the levels of lithium in your blood, so it’s important to consume a steady amount every day.
So, the correct answer is, none of the above.
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