Exhibits
A nurse is caring for a client who has a seizure disorder. (Select all that apply.)
Administer supplemental oxygen to the client.
Restrain the client.
Time the duration of the seizure.
Place a tongue depressor in the client's mouth.
Turn the client to the side
Correct Answer : A,C,E
A. The client is experiencing apnea and has decreased oxygen saturation, indicating a need for supplemental oxygen.
B. Restraining a client during a seizure is dangerous and can cause injury.
C. This information is crucial for determining the type of seizure and guiding treatment.
D. Placing a tongue depressor in the client's mouth can cause trauma to the teeth and mouth and should never be done.
E. Turning the client to the side helps prevent aspiration of saliva or vomit, protecting the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. In DIC, there is actually a consumption of clotting factors rather than an increase. The widespread activation of the clotting cascade leads to the consumption of clotting factors and platelets as they are used up in forming numerous small blood clots throughout the body. This depletion results in a paradoxical bleeding tendency due to a shortage of clotting factors.
B. This is characteristic of DIC. The condition involves both excessive clotting (thrombosis) and bleeding. The formation of small clots throughout the microcirculation leads to organ damage and depletion of clotting factors and platelets, which in turn causes bleeding tendencies. This dual process of clot formation and bleeding is a hallmark of DIC.
C. In DIC, there is a decrease in platelet count, not an increase. The condition causes widespread clotting, which consumes platelets rapidly, leading to a low platelet count. Therefore, a progressive increase in platelet count would not be expected in DIC.
D. Sodium and fluid retention are not primary features of DIC. Instead, DIC typically presents with symptoms related to clotting and bleeding rather than fluid balance. Fluid retention would be more associated with other conditions like heart failure or renal disorders, not directly with DIC.
Correct Answer is A
Explanation
A. Atrial fibrillation is consistent with the symptoms described. It causes irregular palpitations and dizziness due to the rapid and irregular ventricular rate. The significant pulse deficit can occur because the irregular rhythm may lead to intermittent weak or absent pulses. The ECG typically shows an irregular rhythm with no identifiable P waves and an irregularly irregular ventricular response.
B. Sinus bradycardia does not usually cause a rapid and irregular heart rate. It is characterized by a regular rhythm with a slow heart rate. While it can cause fatigue and dizziness, it does not typically present with an irregular rhythm or a significant pulse deficit. Therefore, it is less consistent with the symptoms described.
C. Sinus tachycardia is characterized by a rapid but regular heart rate. It does not typically present with an irregular rhythm or significant pulse deficit. While it may cause symptoms such as palpitations and
dizziness, the regular rhythm and absence of irregularity in the ECG make it less likely to be the cause of the significant irregular pulse deficit described.
D. First-degree AV block does not usually cause a rapid and irregular heart rate. It typically presents with a regular rhythm but with a prolonged PR interval. It is not typically associated with irregular palpitations or a significant pulse deficit. The symptoms described are not characteristic of first-degree AV block.
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