The nurse is teaching a client's family member about seizure precautions. Which action described by the family member indicates the need for additional teaching?

Avoid forcing apart the teeth.

Loosen clothing around the neck.

Position the head from injury.

Secure the limbs to the body.

Answer and Explanation

The Correct Answer is D

A. Avoid forcing apart the teeth: Placing objects in the client’s mouth or trying to pry open the teeth can cause injury. It is important to let the seizure pass without interfering with the jaw or mouth.

B. Loosen clothing around the neck: Loosening tight clothing reduces the risk of airway obstruction or restricted breathing during a seizure. This is a correct and helpful intervention.

C. Position the head from injury: Protecting the client’s head with a soft object prevents trauma during convulsions. This is a recommended and safe practice during seizures.

D. Secure the limbs to the body: Restraining or holding down limbs can cause musculoskeletal injuries and increase agitation. Seizure safety protocols emphasize allowing movement without physical restraint.

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Correct Answer is C

Explanation

A. "Tomorrow I will talk to that nurse about how you were treated last night": This may reinforce the client's black-and-white thinking by validating their perception without exploring the situation. It could also create further conflict or confusion.

B. "I am happy that you are getting better and will be able to go home": This response doesn't address the client's concern and does not help manage the client's dichotomous thinking. It is important to validate the client's feelings and address the issue at hand.

C. "What did the night nurse do that makes you think the nurse is aloof?": This response explores the client's perception in a non-judgmental manner. It encourages the client to reflect on the situation and provides an opportunity for the nurse to gain insight into the client's thought process, helping to address the dichotomous thinking.

D. "I am glad you like me. Which nurse was acting aloof to you?": This response may reinforce the client's idealization of the current nurse and devaluation of the night nurse. It does not address the underlying issue of the client's perception and could encourage further splitting.

A. Maintain the client on an NPO status. B. Determine if the client is over-hydrating to feel satiated. C. Administer daily vitamin supplements. D. Encourage positive self accolades for dietary adherence.

Correct Answer is A

Explanation

A. Maintain the client on an NPO status: After bariatric surgery, vomiting and the inability to tolerate food and liquids could indicate complications such as gastric outlet obstruction or stenosis. Maintaining NPO status allows the gastrointestinal system to rest while the cause of the symptoms is investigated and treated.

B. Determine if the client is over-hydrating to feel satiated: While over-hydration can cause discomfort, the immediate concern is the client's inability to tolerate food and liquids, which may suggest a more serious issue.

C. Administer daily vitamin supplements: While vitamin supplementation is essential after bariatric surgery to prevent deficiencies, it does not directly address the current issue of vomiting and inability to tolerate food and liquids.

D. Encourage positive self accolades for dietary adherence: Though reinforcing positive behavior is important in long-term weight loss management, it is not the priority at this moment. The immediate focus is addressing the client's symptoms and ensuring they are medically managed.

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The nurse is teaching a client's family member about seizure precautions. Which action described by the family member indicates the need for additional teaching?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care?

Correct Answer is A

Explanation

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