In caring for a client who requires seizure precauons, the praccal nurse (PN) should ensure the ready availability of equipment to perform which procedure?

Sucon the trachea.

Insert a urinary catheter.

Apply so restraints.

Insert a nasogastric tube.

Answer and Explanation

The Correct Answer is A

Seizure precauons are measures taken to protect a client who is at risk of having a seizure, which is a sudden and abnormal electrical acvity in the brain that can cause changes in behavior, movement, sensaon, or consciousness. Seizure precauons include providing a safe environment, monitoring the client's vital signs and neurological status, administering anconvulsant medicaons, and documenng the onset, duraon, and characteriscs of any seizure acvity³.

One of the potenal complicaons of a seizure is aspiraon, which is the inhalaon of foreign material into the lungs, such as saliva, vomit, or food. Aspiraon can cause choking, pneumonia, or respiratory distress. To prevent or treat aspiraon, the praccal nurse (PN) should ensure the ready availability of equipment to perform suconing of the trachea, which is the tube that connects the mouth and nose to the lungs. Suconing of the trachea involves inserng a catheter through the nose or mouth into the trachea and applying negave pressure to remove any secreons or debris from the airway.

Therefore, opon A is the correct answer, while opons B, C, and D are incorrect.

Opon B is incorrect because inserng a urinary catheter is not related to seizure precauons or aspiraon prevenon.

Opon C is incorrect because applying so restraints may not be necessary or appropriate for a client who requires seizure precauons, as they may interfere with the natural movements of the seizure or cause injury to the client.

Opon D is incorrect because inserng a nasogastric tube is not related to seizure precauons or aspiraon prevenon.

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Correct Answer is D

Explanation

Choice A reason: Administering corticosteroids is not an action that the nurse implements to increase venous return, prevent stiffness, and maintain muscle strength and endurance because it is a medication that reduces inflammation and relieves acute exacerbations of multiple sclerosis, but does not affect the client's physical function or mobility.

Choice B reason: Turning and repositioning every 2 hours is not an action that the nurse implements to increase venous return, prevent stiffness, and maintain muscle strength and endurance because it is a nursing intervention that prevents pressure ulcers and promotes skin integrity, but does not enhance the client's circulation or muscle activity.

Choice C reason: Administering interferon is not an action that the nurse implements to increase venous return, prevent stiffness, and maintain muscle strength and endurance because it is a medication that modifies the immune system and delays the progression of multiple sclerosis, but does not improve the client's physical function or mobility.

Choice D reason: Encouraging range-of-motion exercises is an action that the nurse implements to increase venous return, prevent stiffness, and maintain muscle strength and endurance because it is a physical activity that improves the client's blood flow, flexibility, and muscle tone, as well as prevents contractures and spasticity.

A. Gradual onset of several hours B. Maintains consciousness C. Sudden severe headache D. History of neurologic deficits lasting less than 1 hour

Correct Answer is C

Explanation

Choice A reason: Gradual onset of several hours is not a manifestation of a hemorrhagic strokE. Hemorrhagic strokes occur when a blood vessel bursts in or near the brain, causing rapid bleeding and increased intracranial pressurE.

Choice B reason: Maintains consciousness is not a manifestation of a hemorrhagic strokE. Hemorrhagic strokes often cause loss of consciousness due to compression or damage of brain tissuE.

Choice C reason: Sudden severe headache is a manifestation of a hemorrhagic strokE. Hemorrhagic strokes can cause intense pain in the head due to bleeding and pressure on nerve endings.

Choice D reason: History of neurologic deficits lasting less than 1 hour is not a manifestation of a hemorrhagic strokE. Neurologic deficits lasting less than 1 hour are more indicative of a transient ischemic attack (TIA), which is caused by temporary blockage or narrowing of blood vessels in or leading to the brain.

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In caring for a client who requires seizure precauons, the praccal nurse (PN) should ensure the ready availability of equipment to perform which procedure?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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