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:
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.
Correct Answer is ["033"]
Explanation
Step 1 is to calculate the number of milliliters (mL) that contain the ordered dose of 300 mg of clindamycin.
Step 2 is to divide the total milliliters (mL) from Step 1 by the infusion time in minutes to get the flow rate in mL/hour. Here are the calculations:
Step 1:
900 mg of clindamycin is in 50 mL.
To find the mL that contain 300 mg, set up a proportion:
(300 mg / 900 mg) = (x mL / 50 mL) Cross-multiply and solve for x:
x = (300 mg * 50 mL) / 900 mg x = 16.67 mL
Step 2:
The infusion time is 30 minutes.
Divide the total mL (16.67 mL) by the infusion time in hours to get the flow rate in mL/hour: Flow rate = 16.67 mL / (30 minutes / 60 minutes/hour)
Flow rate = 33.33 mL/hour
Round to the nearest whole number, using a leading zero if it applies, and no trailing zero: Flow rate = 033 mL/hour
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.