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.
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Related Questions
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.
Correct Answer is B
Explanation
A. Serum amylase levels: Serum amylase is helpful in detecting pancreatitis but is not the most immediate concern with symptoms of fatigue, anorexia, and tachypnea. A CBC is more relevant to evaluate possible anemia or infection.
B. Complete blood count: A CBC is crucial to assess for anemia, infection, or other hematologic issues, which could be causing the client's malaise, fatigue, and tachypnea. This is the most important test to guide further treatment.
C. Arterial blood gases: While useful for assessing respiratory function, ABG testing is not the first priority here. The client's symptoms suggest a more likely hematologic issue that would be better assessed with a CBC.
D. Liver function tests: Liver function tests are important but not the most urgent in this case. The CBC provides a broader view of the client's condition and helps identify the underlying cause of the symptoms.
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