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 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.
Correct Answer is B
Explanation
A. Elevated heart rate and BP may indicate stress or pain, but Kussmaul respirations are more typical of metabolic acidosis (e.g., DKA), not increased ICP.
B. Bradycardia, widening pulse pressure (increased systolic with stable diastolic), and irregular respirations are signs of Cushing’s triad, a late but classic indicator of increased ICP requiring immediate reporting.
C. Vital signs here are stable and within expected ranges; shallow respirations may be related to sedation or fatigue but not increased ICP.
D. This pattern suggests hypotension and compensatory tachycardia, more consistent with hypovolemia or shock than increased ICP.
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