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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Monitor collection container and replace when full: The nurse should monitor the collection container to ensure it doesn't become full, as this could cause backflow into the pleural cavity. Replacing it when full is essential to maintain proper drainage.
B. Encourage frequent use of the incentive spirometer: Using the incentive spirometer helps prevent atelectasis and pneumonia by promoting lung expansion. It is important for postoperative recovery to maintain good respiratory function.
C. Assess area around chest tube for subcutaneous emphysema: Subcutaneous emphysema can occur if air leaks into the tissues around the chest tube. The nurse should check for this condition as it could indicate complications like an air leak or pneumothorax.
D. Keep tubing loosely coiled below the level of the chest: The tubing should be positioned below the chest to facilitate gravity drainage. Keeping it loosely coiled ensures that fluid and air drain efficiently without backflow.
E. Verify air bubbling present in the water seal chamber: Continuous bubbling in the water seal chamber is not expected and may indicate an air leak. Intermittent bubbling may be normal if the lung is still re-expanding, but ongoing bubbling should be reported, not simply verified.
Correct Answer is B
Explanation
A. Tie the knot with a double turn or square knot: While using a secure knot is important, the most critical factor is that the knot can be easily and quickly released in an emergency. A half bow knot may be inadequate for rapid release, but the primary focus should be ensuring quick accessibility.
B. Ensure that the knot can be quickly released: This is the most important action to ensure the safety of the client. In the event of an emergency, such as difficulty breathing or a need to quickly remove restraints, the knot must be easily undone without delay.
C. Move the ties so the restraints are secured to the side rails: Tying restraints to side rails is inappropriate because the side rails can move, which may result in injury. Restraints should be attached to a stationary part of the bed frame.
D. Ensure that the restraints are snug against the client's wrists: While restraints should be applied snugly to prevent injury, they should not be too tight. The primary concern here is ensuring that the restraints are safely and quickly releasable, not just snug.
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