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:
Restricting weight-bearing on the affected foot may provide some temporary relief from pain during an acute gout attack. However, it is not a long-term management strategy and can lead to muscle weakness and joint stiffness. It's important to gradually resume weight-bearing activities as tolerated to maintain joint function.

Choice B rationale:
Adequate fluid intake is essential for overall health and can help to flush out uric acid from the body. However, 8 liters per day is an excessive amount of fluid and could lead to electrolyte imbalances and other health problems. A more appropriate recommendation for a client with gout would be to aim for a fluid intake of 2-3 liters per day, unless otherwise advised by a healthcare provider.

Choice C rationale:
Restricting consumption of foods high in purines is a key management strategy for gout. Purines are substances found in certain foods that break down into uric acid in the body. High levels of uric acid can lead to the formation of urate crystals, which deposit in joints and cause inflammation and pain. Examples of foods high in purines include organ meats, red meat, seafood, and some types of beans and lentils.

Choice D rationale:
Calcium supplements have not been shown to be effective in the management of gout. In fact, some studies have suggested that calcium supplements may even increase the risk of gout attacks.

A. Develops an acute retroviral syndrome B. Has a CD4+ T lymphocyte level of less than 200 cells/mm C. Is capable of transmitting the virus to others D. Contracts HIV-specific antibodies A nurse is caring for a client who has been diagnosed as HIV positive.

Correct Answer is B

Explanation

Choice A rationale:
Acute retroviral syndrome (ARS) is an early stage of HIV infection that often presents with flu-like symptoms. It does not determine AIDS diagnosis.

Choice B rationale:
A CD4+ T lymphocyte level of less than 200 cells/mm is a defining criterion for AIDS diagnosis. This low count indicates a severely weakened immune system, leading to susceptibility to opportunistic infections and other AIDS-defining illnesses.

Choice C rationale:
A person with HIV can transmit the virus to others regardless of their CD4+ T cell count. Transmission risk is not a diagnostic criterion for AIDS.

Choice D rationale:
HIV-specific antibodies are produced by the immune system in response to HIV infection but their presence does not signify AIDS progression.

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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)

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Naxlex Comprehensive Predictor Exams

A client comes to the clinic with a complaint of pain in the right great toe and is eventually diagnosed with gout. When planning teaching for this client, what management technique should the nurse emphasize?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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