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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Providing a urine sample to determine therapeutic levels of phenytoin is not typically a part of routine discharge instructions. While monitoring of phenytoin levels is important, it's usually done through blood tests, and the frequency of testing is determined by the healthcare provider based on individual patient factors.
Choice C rationale:
Bleeding gums are not a common side effect of phenytoin. While some individuals might experience gum tenderness or overgrowth, significant bleeding is not expected.
Choice D rationale:
Antacids can actually interfere with the absorption of phenytoin, potentially reducing its effectiveness. Therefore, it's generally not recommended to take antacids regularly while on phenytoin therapy. If a patient needs to take an antacid for occasional heartburn or indigestion, it's best to take it at least 2 hours before or after the phenytoin dose.
Correct Answer is B
Explanation
Choice A rationale:
While taking colchicine with food can help minimize gastrointestinal side effects like nausea, it's not the most crucial instruction for this medication. The primary concern with colchicine is its potential for muscle toxicity.
Choice B rationale:
Colchicine can cause muscle pain, tenderness, or weakness, which can be a sign of a serious condition called rhabdomyolysis. Rhabdomyolysis involves the breakdown of muscle tissue, potentially leading to kidney damage and other complications.
It's crucial for patients to monitor for muscle pain and report it to their healthcare provider promptly if it occurs. Early detection and intervention can help prevent serious complications.
Choice C rationale:
Increased bruising is not a common side effect of colchicine. It's more frequently associated with medications that affect blood clotting, such as warfarin or aspirin.
Choice D rationale:
Grapefruit juice can interact with many medications, including colchicine. It can increase the concentration of colchicine in the bloodstream, potentially leading to toxicity.
It's crucial for patients taking colchicine to avoid grapefruit juice and other grapefruit products.
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