While waiting for an appointment in the doctor’s office, a patient experiences a convulsive seizure. The nurse is immediately notified.
What nursing care should be provided at this time? (Select all that apply.)

Open the patient’s jaw and insert a mouth gag

Move furniture away from the patient

Loosen constrictive clothing

Provide privacy

Restrain the patient to avoid self-injury

Position the patient on their side with their head flexed forward

Answer and Explanation

Correct Answer : B,C,D,F

Choice A rationale
It is a common misconception that something should be placed in the mouth of someone having a seizure to prevent them from biting their tongue. However, this can cause more harm than good, including injury to the person’s mouth or the rescuer’s fingers.
Choice B rationale
Moving furniture away from the person having a seizure can help prevent injury. During a seizure, a person may move uncontrollably, and removing nearby objects can reduce the risk of harm.
Choice C rationale
Loosening constrictive clothing can help the person breathe more easily during and after a seizure.
Choice D rationale
Providing privacy can help maintain the person’s dignity and reduce embarrassment after a seizure.
Choice E rationale
It is not recommended to restrain a person during a seizure. This can result in injury. Instead, the goal is to keep the person safe until the seizure stops on its own.
Choice F rationale

Positioning the person on their side with their head flexed forward can help prevent aspiration, which can occur if the person vomits during or after a seizure.

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Correct Answer is C

Explanation

Choice A rationale
While assessing visual acuity may be part of a comprehensive eye examination, it would not specifically address distortions noted on the Amsler grid.
Choice B rationale
Tonometry testing is used to measure the pressure inside the eye and is typically used in the diagnosis of glaucoma. It would not specifically address distortions noted on the Amsler grid.
Choice C rationale
Distortions when looking at the Amsler grid can be a sign of macular degeneration16. Therefore, arranging for the client to be assessed for macular degeneration would be the appropriate action16.
Choice D rationale
While age-related changes in vision can occur, distortions when looking at the Amsler grid are not typically considered a normal age-related change16. Therefore, reassuring the client that this is an age-related change in vision would not be the appropriate action16.

A. Keep a urinary catheter in place for the entire duration of recovery. B. Provide three larger meals rather than frequent small meals. C. Limit the intake of insoluble fiber. D. Teach the patient to perform deep breathing and coughing exercises.

Correct Answer is D

Explanation

Choice D rationale
Teaching the patient to perform deep breathing and coughing exercises is a key intervention to address a potential complication after an ischemic stroke. These exercises can help prevent pneumonia, a common complication after stroke, by promoting lung expansion, improving oxygenation, and facilitating the clearance of secretions.
Choice A rationale
Keeping a urinary catheter in place for the entire duration of recovery is not typically recommended due to the increased risk of urinary tract infections. Catheters should be used sparingly and removed as soon as possible.

Choice B rationale
Providing three larger meals rather than frequent small meals does not specifically address a potential complication after an ischemic stroke. In fact, smaller, more frequent meals may be easier for some stroke patients to manage, particularly if they have difficulty swallowing.
Choice C rationale
Limiting the intake of insoluble fiber does not specifically address a potential complication after an ischemic stroke. A balanced diet with adequate fiber is generally recommended for stroke patients to promote bowel regularity and overall health.

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While waiting for an appointment in the doctor’s office, a patient experiences a convulsive seizure. The nurse is immediately notified. What nursing care should be provided at this time? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has informed the Home Health Nurse that they recently noticed distortions when looking at the Amsler grid kept on their refrigerator. What is the appropriate action for the nurse to take?

Correct Answer is C

Explanation

The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke?

Correct Answer is D

Explanation

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While waiting for an appointment in the doctor’s office, a patient experiences a convulsive seizure. The nurse is immediately notified. What nursing care should be provided at this time? (Select all that apply.)

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While waiting for an appointment in the doctor’s office, a patient experiences a convulsive seizure. The nurse is immediately notified.
What nursing care should be provided at this time? (Select all that apply.)