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
The Rinne test is a hearing test used to evaluate the difference between sound transmission through air conduction versus bone conduction. It is not typically used following a Romberg test, which evaluates balance.
Choice B rationale
While ensuring the patient’s safety is always important, repositioning the client supine is not the typical response to slight swaying during a Romberg test.
Choice C rationale
Slight swaying during a Romberg test is considered normal. Therefore, documenting successful completion of the assessment would be the appropriate action.
Choice D rationale
A referral to a neurologist is not typically necessary for slight swaying during a Romberg test, as this is considered within normal limits.

A. Facial droop B. Dysrhythmias C. Periorbital edema D. Projectile vomiting

Correct Answer is A

Explanation

Choice A rationale
Facial droop is a classic symptom of stroke. It occurs when there’s weakness or paralysis on one side of the face, which is caused by a disruption in the nerve signals due to a stroke. This can be easily observed in the person’s smile, as it will appear uneven.
Choice B rationale
While dysrhythmias can be associated with stroke, they are not the most indicative symptom. Dysrhythmias are more commonly associated with heart conditions.
Choice C rationale
Periorbital edema, or swelling around the eyes, is not typically a symptom of stroke. It can be caused by various conditions such as allergies, infections, or kidney problems.

Choice D rationale
Projectile vomiting is not typically a symptom of stroke. It can be caused by various conditions such as gastrointestinal issues, brain tumors, or increased intracranial pressure.

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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

During the performance of a Romberg test, the nurse observes the client sway slightly. What action should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is A

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.)