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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Tenderness: Tenderness during percussion could indicate an underlying issue, such as inflammation or infection, and is not a normal finding.

B. Pain: Pain during percussion may suggest problems like organ inflammation or distension and is not considered normal.

C. Musical and drumlike: This finding is normal and is often indicative of the presence of air or gas in the intestines, which is a common finding in older adults, especially those with less efficient digestion.

D. Absent sounds: Absent sounds could indicate bowel obstruction or other serious issues and are not a normal finding. Normal percussive sounds should be heard.

A. Leakage of cerebral spinal fluid from the incisional site. B. Poor feeding and vomiting. C. Abdominal distention. D. WBC of 10,000/mm3 (10 x 10^ 9/L). E. Hyperactive bowel sounds.

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

Explanation

A. Leakage of cerebral spinal fluid from the incisional site: Leakage of cerebrospinal fluid (CSF) from the incision site is a serious postoperative complication. It could indicate a shunt malfunction or infection, requiring immediate attention.

B. Poor feeding and vomiting: These symptoms may indicate increased intracranial pressure, which can result from a shunt malfunction or infection, both serious complications that need to be addressed immediately.

C. Abdominal distention: Abdominal distention in an infant with a VP shunt can indicate an issue with the peritoneal end of the shunt. This could be due to malabsorption of CSF in the peritoneal cavity, infection (peritonitis), or kinking/blockage of the catheter in the abdomen, leading to accumulation of fluid and distention.

D. WBC of 10,000/mm3 (10 x 10^9/L): A WBC count of 10,000/mm3 is within the normal range for a one-week-old infant. Therefore, this finding does not indicate infection or an inflammatory response and is not a concern in this case.

E. Hyperactive bowel sounds: Hyperactive bowel sounds are typically not associated with a VP shunt complication. This finding is generally indicative of gastrointestinal motility, which is not related to a shunt malfunction or infection.

View Question and Answer

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

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

The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client?

Correct Answer is C

Explanation

The nurse is caring for a one-week-old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which finding(s) indicate a postoperative complication? Select all that apply. Reference Range: White blood cells (WBC) [9,000 to 10,000/mm3 (9 to 10 x 10^9 /L)]

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

Explanation

The nurse is caring for a client who underwent a right lobectomy for lung cancer 24 hours ago and has a single chest tube on the right side. Which intervention(s) should the nurse plan to implement? Select all that apply.

The nurse is speaking with the spouse of a client who has passed away unexpectedly. The spouse is very calm and says, "No, there must be a mistake." Which action should the nurse take?

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

Exhibits The client has received a medical diagnosis of rheumatoid arthritis (RA). The client should receive education about living and managing her condition and how to minimize disease complications. Which education should be given to the client by the nurse? Select all that apply.