After placing a client who is having a seizure in the side-lying position, which intervention should the nurse implement?
Apply soft restraints to all extremities.
Remove objects that could cause injury.
Place pillows around the client's head.
Administer oxygen per nasal cannula.
The Correct Answer is B
Choice A reason: Applying soft restraints to all extremities is not appropriate during a seizure as it can increase the risk of injury. The priority is to ensure the client's safety by preventing injury without restraining them.
Choice B reason: Removing objects that could cause injury is crucial. During a seizure, the client may move unpredictably, and any nearby objects could pose a risk of harm. Clearing the area ensures the client has a safe space to have the seizure without additional hazards.
Choice C reason: Placing pillows around the client's head can provide some protection, but it is not as immediately effective or necessary as removing potentially harmful objects from the surrounding area. Ensuring a clear and safe environment is the primary concern.
Choice D reason: Administering oxygen per nasal cannula is not the first priority during a seizure. While maintaining oxygenation is important, the immediate focus should be on ensuring the client's physical safety by removing dangerous objects. Once the seizure subsides, appropriate respiratory support can be provided if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Reporting black stools to the healthcare provider is important because black stools can indicate gastrointestinal bleeding, which is a serious complication of gastritis. This statement reflects proper understanding and does not need additional education.
Choice B reason: Consuming caffeine in moderation is advisable because excessive caffeine can irritate the stomach lining and exacerbate gastritis symptoms. This statement is correct and shows proper understanding.
Choice C reason: Drinking plenty of water with meals might seem beneficial, but it can actually dilute stomach acid and interfere with digestion, potentially worsening gastritis symptoms. Instead, it is recommended to drink water between meals to stay hydrated without impacting digestion.
Choice D reason: Avoiding ibuprofen for headaches is important because nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can irritate the stomach lining and worsen gastritis. This statement reflects proper understanding and does not need additional education.
Correct Answer is A
Explanation
Choice A reason: Upper midabdominal pain described as gnawing and burning is a classic symptom of peptic ulcer disease (PUD). This type of pain is typically located in the epigastric region and is often relieved by eating or taking antacids, which aligns with the presentation of PUD.
Choice B reason: Marked loss of weight and appetite over the last 3 or 4 months can occur in various gastrointestinal conditions, but it is not specific enough to support a diagnosis of PUD. This symptom alone does not provide enough evidence for PUD.
Choice C reason: Severe abdominal cramps and diarrhea after eating spicy foods might indicate irritable bowel syndrome (IBS) or another gastrointestinal condition. These symptoms are not typically associated with PUD.
Choice D reason: Frequent use of chewable and liquid antacids for indigestion can indicate chronic gastrointestinal discomfort, but it does not specifically point to PUD. It suggests ongoing gastric issues but lacks specificity for diagnosing PUD.
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