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 D

Explanation

A. Ask family members to remain with the client in the evenings from 1700 to 2100: While family presence can offer comfort, it is not always feasible and doesn’t directly address the environmental management needed for sundowning behaviors.

B. Administer a prescribed PRN benzodiazepine at the onset of a confused state: Though medications may help in acute cases, routine pharmacologic management is not the first-line intervention due to risks like oversedation and increased fall risk in older adults.

C. Postpone administration of nighttime medications until after 2300: Delaying medications may interfere with sleep hygiene and the efficacy of routine medications that aid in rest or symptom management.

D. Ensure that the client is assigned to a room close to the nurses' station: Proximity to staff allows for more frequent monitoring and faster intervention during episodes of confusion, helping prevent injury and manage behaviors associated with sundowning.

A. Contagious until symptoms subside. B. Sandpaper-like rash. C. Peeling and flaking skin in a week. D. Darkening of skin under arms. E. Fever lasting for 7 to 10 days.

Correct Answer is ["B","C"]

Explanation

A. Contagious until symptoms subside: Streptococcal pharyngitis is contagious until 24 hours after starting antibiotics, not until all symptoms are gone. This is important for limiting transmission to others in the household or school setting.

B. Sandpaper-like rash: A sandpaper-textured rash is a hallmark sign of scarlet fever, which is a complication of strep throat. It usually begins on the neck or chest and spreads, often feeling coarse to the touch.

C. Peeling and flaking skin in a week: Desquamation, or skin peeling, is common several days after a strep rash subsides, particularly on the hands and feet. This symptom signals the healing phase of scarlet fever.

D. Darkening of skin under arms: Darkened underarm skin is typically linked to acanthosis nigricans, associated with insulin resistance or obesity. It is not seen with streptococcal infections or fever-related conditions.

E. Fever lasting for 7 to 10 days: Fever from strep throat usually resolves quickly within 24–48 hours of initiating antibiotic therapy. Prolonged fever would be atypical and requires further evaluation for complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The nurse notices that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the nurse to implement?

Correct Answer is D

Explanation

Correct Answer is ["B","C"]

Explanation

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