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 A

Explanation

Rationale for Choice A:
Phenytoin is an anticonvulsant medication used to control seizures. It is typically a long-term medication, and abruptly stopping it can lead to breakthrough seizures or worsen existing seizures.
This statement indicates that the client may not understand the importance of taking phenytoin consistently and the potential consequences of discontinuing it without consulting their doctor.

Rationale for Choice B:
Making an appointment with a dentist is important for all individuals, including those with seizure disorders. There is no specific concern related to phenytoin and dental care that would necessitate further teaching in this context.

Rationale for Choice C:
It is important for clients to understand that switching brands of phenytoin might affect its effectiveness due to slight variations in formulation. However, simply stating awareness of this fact does not necessarily indicate a need for further teaching, as the nurse can assess the client's understanding through further questioning.

Rationale for Choice D:
Notifying a doctor before taking any new medications is crucial for individuals with seizures, as some medications can interact with phenytoin and increase the risk of seizures. This statement demonstrates the client's understanding of an important safety precaution.
Therefore, Choice A is the only statement that suggests a potential lack of understanding about the long-term nature of phenytoin treatment and the dangers of discontinuing it without medical supervision. This highlights the need for further education to ensure the client's safety and adherence to the prescribed medication regimen.

A. I will closely follow a high-purine diet B. I will take one aspirin per day C. I will limit my alcohol intake D. I will limit my fluid intake to 1 liter per day

Correct Answer is C

Explanation

Choice A rationale:
A high-purine diet is actually contraindicated in gout because purines are metabolized into uric acid, which can accumulate in the joints and trigger gout attacks. Therefore, a low-purine diet is recommended.

Choice B rationale:
Aspirin is not typically recommended for gout because it can interfere with the excretion of uric acid and potentially worsen the condition. While low-dose aspirin might be used for specific cardiovascular benefits in some gout patients, it's not a general treatment for gout itself.

Choice C rationale:Alcohol intake is a common trigger for gout attacks because it can increase uric acid levels in the blood. Therefore, limiting alcohol intake is an important part of managing gout.

Choice D rationale:
Fluid intake should be increased, not limited, in gout patients. This is because adequate hydration helps to flush uric acid out of the body and reduce the risk of gout attacks.

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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 nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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