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The client is a young male who appears to be 25-30 years old. He was found unconscious on a sidewalk by a jogger who was passing. The jogger called an ambulance, and the EMT's transported the ent to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT CT of the head in the emergency room showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.

The PN reinforces education about seizures to the client and asks him to explain what he understands about his condition.

Which statements indicate understanding?

Select all that apply

"I don't need to go to the hospital if I have another seizure unless it is a very long seizure or if I have several in a row."

"There are really no lifestyle changes that I can do that will affect my risk of having another seizure."

"I may never know why I started having seizures."

"Having a medic alert bracelet might be a good idea, but it is up to me to decide if I want it or not."

"I can stop taking the phenytoin if I go for a while and don't have a seizure."

Answer and Explanation

Correct Answer : A,C,D

A. "I don't need to go to the hospital if I have another seizure unless it is a very long seizure or if I have several in a row." This statement demonstrates an understanding that certain characteristics of seizures, such as prolonged duration or multiple seizures in succession, may require medical attention and evaluation.
C. "I may never know why I started having seizures." This statement acknowledges the possibility that the underlying cause of the seizures may remain unknown. Seizure etiology can vary, and in some cases, the specific cause cannot be determined despite diagnostic tests.
D. "Having a medic alert bracelet might be a good idea, but it is up to me to decide if I want it or not." This statement recognizes the potential benefits of wearing a medic alert bracelet, which can provide crucial information about the client's condition in case of emergencies. It emphasizes the client's autonomy in making the decision, showing an understanding of the role and significance of the bracelet.
The following statement does not indicate understanding:

"There are really no lifestyle changes that I can do that will affect my risk of having another seizure." This statement is incorrect, as there are lifestyle modifications that can help reduce the risk of seizures, such as getting enough sleep, managing stress, avoiding triggers (if known), and taking prescribed medications as directed.
Regarding the statement "I can stop taking the phenytoin if I go for a while and don't have a seizure," it is not included in the given options.

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Correct Answer is C

Explanation

A. Reporting any drainage observed around the gastrostomy tube insertion site is important for monitoring potential infection or complications; however, it is not the most immediate concern during a total bed bath.
B. While using plenty of pillows to position the client on the side after bathing is important for comfort and skin integrity, it does not address the safety of the feeding during the bath.
C. Keeping the head of the bed raised while the tube feeding is infusing is the most critical instruction. This position helps prevent aspiration and ensures that the feeding is administered safely while maintaining the client’s airway during the bathing process.
D. Raising the entire bed while bathing the client is helpful for the caregiver's ergonomics but does not take precedence over ensuring the client’s safety regarding the gastrostomy tube feeding.

A. Determine if the UAP would like assistance. B. Instruct the UAP to lower the bed for safety. C. Assume care of the client immediately. D. Remain in the room to supervise the UAP.

Correct Answer is B

Explanation

Bathing a bedfast client with the bed in a high position poses a potential risk to the client's safety. Lowering the bed to a safe height is important to prevent falls and injuries during the bathing procedure. The PN should promptly intervene and instruct the UAP to lower the bed to an appropriate level before continuing with the bathing process.
A. While remaining in the room to supervise the UAP is important, it should be done after ensuring the client's safety by lowering the bed. If the bed is not lowered, the risk of injury remains, and the PN should take immediate action to address the safety concern.
C. Determining if the UAP would like assistance is a valid consideration, but it should be secondary to addressing the safety issue of the bed height. Once the bed is lowered, the PN can assess if additional assistance is required and provide support accordingly.
D. Assuming care of the client immediately may be necessary if the client is in immediate danger or experiencing an urgent medical situation. However, in this case, the primary concern is addressing the safety issue related to the bed height, and the PN can address this by instructing the UAP to lower the bed.

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has continuous feeding via a gastrostomy tube (GT). Which instruction is most important for the PN to emphasize?

Correct Answer is C

Explanation

The practical nurse (PN) observes unlicensed assistive personnel (UAP) bathing a bedfast client with the bed in a high position. Which action should the PN take?

Correct Answer is B

Explanation

Exhibits here Review H and P and nurse's notes. What other assessment techniques can the nurse use to identify the potential source of the client's new-onset confusion and decreased appetite? Select all that apply.

The PN Identifies that the client is having a tonic-clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/min. The PN calls for help and 2 other PNs enter the room. Which three actions will the PN anticipate taking next?

The parents of a one-year-old child with the diagnosis of hypospadias informed the practical nurse (PN) that they plan to delay corrective surgery to see if the child will outgrow the problem. Which information should the PN provide to these parents?

Which information should the practical nurse (PN) collect during the admission assessment of a terminally ill client to an acute care facility?

A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange. Which question should the PN ask the client next?

Ancient is scheduled for a thoracentesis that will be done at the bedside. What should the practical nurse (PN) prepare before the healthcare provider arrives to perform the procedure?

The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) take in this situation?

The practical nurse (PN) is preparing a client for discharge who receives a prescription for oral prednisone to treat a severe allergic reaction. Which teaching about medication administration should the PN reinforce?