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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Bronchial airway constriction: In the fight-or-flight response, bronchial airways actually dilate to increase airflow to the lungs, rather than constricting.
B. Hypoglycemia: The fight-or-flight response typically leads to increased blood glucose levels (hyperglycemia) to provide quick energy, not decreased levels.
C. Dilated pupils: During the fight-or-flight response, pupils dilate to improve vision and help the individual better detect threats. This is a classic manifestation of this stress response.
D. Decreased blood pressure: The fight-or-flight response generally increases blood pressure due to the release of adrenaline and other stress hormones that prepare the body for immediate action.

A. Involves respiratory therapy for altered breathing from severe anxiety levels. B. Delegates assessment of lung sounds to nursing assistive personnel. C. Becomes solely responsible for modifying activities of daily living. D. Consults physical therapy for strengthening exercises in the extremities.

Correct Answer is D

Explanation

A. Involves respiratory therapy for altered breathing from severe anxiety levels: This behavior demonstrates collaboration with other healthcare professionals but does not directly relate to a team approach for managing mobility issues.
B. Delegates assessment of lung sounds to nursing assistive personnel: Delegation of tasks such as assessing lung sounds is a nursing responsibility but does not involve the broader team approach necessary for comprehensive care.
C. Becomes solely responsible for modifying activities of daily living: Handling all aspects of a patient's care individually does not reflect a team approach, which involves collaborating with various specialists.
D. Consults physical therapy for strengthening exercises in the extremities: This behavior exemplifies a team approach by involving physical therapy specialists to address mobility issues. It reflects collaboration with other disciplines to provide comprehensive care.

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Which nursing action would be appropriate to protect a patient during a seizure? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a class about physical manifestations associated with the fight-or-flight response to stress. Which of the following manifestations should the nurse include?

Correct Answer is C

Explanation

Which behavior indicates the nurse is using a team approach when caring for a patient who is experiencing alterations in mobility?

Correct Answer is D

Explanation

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