While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?

Restrain the patient's arms and legs to prevent injury during the seizure.

Time and observe and record the details of the seizure and postictal state.

Insert an oral airway during the seizure to maintain a patent airway.

Avoid touching the patient to prevent further nervous system stimulation.

Answer and Explanation

The Correct Answer is B

A. Restrain the patient's arms and legs to prevent injury during the seizure: Restraint during a seizure can potentially cause harm to the patient and should be avoided. It is essential to ensure the patient's safety by protecting the head and providing a safe environment.

B. Time and observe and record the details of the seizure and postictal state: Timing the seizure, observing the type and duration of movements, and noting any changes in the patient's behavior during the postictal state are crucial for documenting the seizure accurately and guiding further management.

C. Insert an oral airway during the seizure to maintain a patent airway: Inserting an oral airway during an active seizure is not recommended and can increase the risk of injury to the patient's airway. Maintaining a clear airway is important, but interventions such as positioning and
suctioning may be sufficient without the need for airway adjuncts during the seizure.

D. Avoid touching the patient to prevent further nervous system stimulation: While it's essential to minimize stimulation during a seizure, avoiding touching the patient altogether may not be feasible or necessary for providing care. Ensuring a safe environment and providing appropriate support are priorities during a seizure.

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Correct Answer is B

Explanation

A. Oriented to person, place, and year: Meningitis often causes alterations in mental status, including confusion and disorientation. Therefore, the client may not be fully oriented to person, place, and time.

B. Severe headache: Headache is a hallmark symptom of meningitis and is often described as severe and persistent. It may be accompanied by other symptoms such as photophobia (sensitivity to light) and phonophobia (sensitivity to sound).

C. Bradycardia: Bradycardia is not typically associated with meningitis. In fact, tachycardia (elevated heart rate) may be present due to fever and systemic inflammation.

D. Blurred vision: While meningitis can lead to increased intracranial pressure, which may manifest as papilledema (swelling of the optic disc), blurred vision is not a common presenting symptom of meningitis. Visual changes are more commonly associated with conditions affecting the optic nerve or retina.

A. Place suction equipment at the client's bedside. B. Provide range-of-motion exercises to the client's neck and shoulders. C. Apply an eye patch to the client's right eye. D. Avoid the use of warm water to wash the client's face.

Correct Answer is A

Explanation

A. Place suction equipment at the client's bedside: Impairment of cranial nerves IX and X can lead to difficulty swallowing and impaired gag reflex, increasing the risk of aspiration and airway obstruction. Therefore, having suction equipment readily available is essential to maintain a patent airway and manage secretions effectively.

B. Provide range-of-motion exercises to the client's neck and shoulders: While range-of-motion exercises may be beneficial for preventing muscle stiffness and contractures, they are not directly related to the client's risk of airway compromise or aspiration.

C. Apply an eye patch to the client's right eye: Acoustic neuroma typically affects cranial nerves VII and VIII, leading to symptoms such as hearing loss and facial weakness. Applying an eye patch to the client's right eye is not necessary for cranial nerve IX and X impairment unless there are specific ocular symptoms.

D. Avoid the use of warm water to wash the client's face: Warm water may be used to wash the client's face safely and is not contraindicated specifically for a client with impairment of cranial nerves IX and X. However, precautions should be taken to ensure that water does not enter the airway if the client has difficulty swallowing or impaired gag reflex.

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While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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