The client tells the nurse, "I am about to have a seizure." Which of the actions should the nurse implement? (Select all that apply)

Loosen the patient's clothing

Ease the patient to the floor if standing

Restrain the patient

Protect the patient's mouth with a padded tongue blade

Provide privacy

Answer and Explanation

Correct Answer : A,B,E

Choice A rationale:
Loosening the patient's clothing around the neck and chest promotes easier breathing during the seizure. It also prevents potential injury from constrictive clothing that could restrict movement or circulation.
Choice B rationale:
Easing the patient to the floor if they are standing helps to prevent falls and injuries that could occur due to loss of consciousness and muscle control during the seizure. It's crucial to guide the patient gently to the floor to avoid abrupt movements that could trigger or worsen the seizure.
Choice C rationale:
Restraining the patient during a seizure is not recommended as it can cause harm. Attempting to restrain a patient's movements during a seizure can lead to muscle strains, joint injuries, or even fractures. It can also increase anxiety and agitation, potentially prolonging the seizure.
Choice D rationale:
Protecting the patient's mouth with a padded tongue blade is not necessary and can even be dangerous. It was once a common practice, but it's now discouraged as it can cause oral injuries, obstruct the airway, or induce vomiting.

Choice E rationale:
Providing privacy helps to protect the patient's dignity and reduce any potential embarrassment during the seizure. It also creates a calmer and less stimulating environment, which can be beneficial in managing the seizure.

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Correct Answer is C

Explanation

Choice A rationale:
While inquiring about pre-seizure symptoms can be informative, it's not the most crucial question at this point. The priority is to gather information about medication adherence to assess potential causes for the breakthrough seizure.

Choice B rationale:
Assessing for post-ictal fatigue is important, but it's not the most pressing question in the immediate aftermath of a seizure. Determining medication adherence takes precedence.

Choice D rationale:
Establishing whether consciousness was lost can aid in classifying seizure type, but it's not as critical as understanding medication adherence in the initial assessment.

Choice C rationale:
This question directly addresses a potential cause of the seizure. Understanding when the client last took their medication can help determine if missed or delayed doses contributed to the seizure, guide medication adjustments, and inform further seizure prevention strategies.

A. Exercise B. Diet C. Sunlight D. Infection

Correct Answer is A

Explanation

The correct answer is A. Exercise.

Choice A: Exercise Exercise is generally beneficial for overall health and is not typically a factor that exacerbates systemic lupus erythematosus (SLE). In fact, regular physical activity can be an important part of the overall treatment plan for individuals with SLE. It can boost energy levels, improve joint flexibility, and help alleviate stress. Therefore, if a patient with SLE identifies exercise as a factor that can exacerbate their condition, it indicates a need for further teaching.

Choice B: Diet Certain diets can potentially trigger or worsen SLE symptoms. For instance, a chemical found in alfalfa may trigger lupus symptoms, so patients may want to avoid eating alfalfa sprouts or taking supplements with alfalfa. Therefore, diet is a correct factor that can exacerbate SLE.

Choice C: Sunlight Exposure to sunlight can trigger or worsen SLE symptoms. For those with lupus, being in the sun can lead to symptoms like skin rashes, itching, burning, joint pain, weakness, and fatigue. In certain cases, it can also result in damage to internal organs. Therefore, sunlight is a correct factor that can exacerbate SLE.

Choice D: Infection Infections can trigger or worsen SLE symptoms. Rates of infections are higher among persons with SLE compared with the general population. Therefore, infection is a correct factor that can exacerbate SLE.

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The client tells the nurse, "I am about to have a seizure." Which of the actions should the nurse implement? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of seizures is being admitted to the emergency room after experiencing a partial seizure. Which question would be most appropriate for the nurse to ask the client?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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