Which nursing action would be appropriate to protect a patient during a seizure? (Select all that apply)
Placing a pad under the patient's head after guiding them to the floor from a standing position
Avoiding placing any objects in the mouth when the patient's teeth are clenched
Guiding the patient to the bed from the floor during a seizure
Turning the patient to one side, having a slightly forward-tilted head
Using supporting pillows for the patient who is on bed
Correct Answer : A,B,D,E
A. Placing a pad under the patient's head after guiding them to the floor from a standing position: This helps to protect the head from injury if the patient falls. However, guiding the patient to the floor should only be done if it is safe and possible to do so without causing further injury.
B. Avoiding placing any objects in the mouth when the patient's teeth are clenched: This prevents the risk of choking or damaging the patient's teeth. It is a common safety measure during seizures.
C. Guiding the patient to the bed from the floor during a seizure: This action is not appropriate during the seizure itself as it may cause injury or disrupt the patient's movement. Instead, the patient should remain in a safe position until the seizure ends.
D. Turning the patient to one side, having a slightly forward-tilted head: This helps to prevent aspiration and facilitates easier breathing during and after the seizure.
E. Using supporting pillows for the patient who is on bed: This helps to protect the patient from injury and provides support, ensuring safety during and after the seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ask the client to demonstrate walking with the cane: Correct. Evaluation involves assessing the client’s ability to perform the learned skill, which is done by asking the client to demonstrate walking with the cane.
B. Show the client a video about walking with a cane: This is part of the teaching process, not evaluation. It is used to provide information but does not assess the client's understanding or ability.
C. Identify short-term goals for the client: This is part of the planning stage, where goals are set to guide the teaching and learning process, not part of evaluation.
D. Determine the client's readiness to learn: This is an initial assessment step before teaching begins, not part of the evaluation process after teaching has occurred.
Correct Answer is D
Explanation
A. Episodic acute stress: This term is not commonly used in clinical practice and does not accurately describe the condition associated with recurring flashbacks of a past traumatic event.
B. Irritable bowel syndrome (IBS): IBS is a gastrointestinal disorder and is not related to the psychological symptoms described, such as flashbacks of traumatic events.
C. Acute stress disorder (ASD): ASD occurs within the first month after a traumatic event and involves symptoms like flashbacks, but since the traumatic event occurred a year ago, it is more consistent with PTSD.
D. Posttraumatic stress disorder (PTSD): PTSD is characterized by persistent symptoms such as flashbacks, intrusive memories, and severe anxiety that occur long after the traumatic event, fitting the client's reported symptoms.
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