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NurseDive Free Nursing Practice Question
A nurse is reinforcing discharge teaching to a client who has epilepsy. Which of the following instructions should be included in the teaching?
A. Placing padding around or under the patient's head
Placing padding around or under the patient's headThis is a helpful instruction to include. Placing padding around or under the patient's head can help prevent injury during a seizure by cushioning the head against impact with the ground.
B. Positioning the patient on the side once the relaxation stage is entered to allow oral secretions to drain
Positioning the patient on the side once the relaxation stage is entered to allow oral secretions to drainThis is a correct instruction. Positioning the patient on their side (recovery position) can help prevent aspiration if vomiting occurs during or after the seizure. It also helps clear oral secretions and maintain a clear airway.
C. Have the necessary equipment and/or personnel in case the patient doesn't spontaneously breath when the seizure is over
Having the necessary equipment and/or personnel in case the patient doesn't spontaneously breathe when the seizure is overThis is an important instruction. It is crucial to have emergency equipment (such as oxygen and suction) readily available and to be prepared to provide respiratory support if the patient does not spontaneously breathe after the seizure.
D. Insert a tongue depressor in the patient's mouth
Inserting a tongue depressor in the patient's mouthThis is an incorrect instruction. It is not recommended to insert anything into the patient's mouth during a seizure as it can cause injury to the teeth, gums, or airway. Additionally, it is a common misconception that tongue swallowing occurs during seizures, which is rare.
E. Note the time the seizure started
This is a critical instruction. Noting the time the seizure started helps healthcare providers assess the duration of the seizure and determine if medical intervention is necessary. It also helps monitor the patient's recovery and response to treatment.
F. Hold the patient down to prevent injury
This is an incorrect instruction. Holding the patient down during a seizure can cause injury to both the patient and the person restraining them. It is important to create a safe environment by removing hazards and guiding the patient away from dangerous objects or situations, but holding them down is not appropriate.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Lpn Med Surg Neuro Test 2024 Proctored Exam. Take the full exam now
Full Explanation
A. Placing padding around or under the patient's head
This is a helpful instruction to include. Placing padding around or under the patient's head can help prevent injury during a seizure by cushioning the head against impact with the ground.
B. Positioning the patient on the side once the relaxation stage is entered to allow oral secretions to drain
This is a correct instruction. Positioning the patient on their side (recovery position) can help prevent aspiration if vomiting occurs during or after the seizure. It also helps clear oral secretions and maintain a clear airway.
C. Having the necessary equipment and/or personnel in case the patient doesn't spontaneously breathe when the seizure is over
This is an important instruction. It is crucial to have emergency equipment (such as oxygen and suction) readily available and to be prepared to provide respiratory support if the patient does not spontaneously breathe after the seizure.
D. Inserting a tongue depressor in the patient's mouth
This is an incorrect instruction. It is not recommended to insert anything into the patient's mouth during a seizure as it can cause injury to the teeth, gums, or airway. Additionally, it is a common misconception that tongue swallowing occurs during seizures, which is rare.
E. Noting the time the seizure started
This is a critical instruction. Noting the time the seizure started helps healthcare providers assess the duration of the seizure and determine if medical intervention is necessary. It also helps monitor the patient's recovery and response to treatment.
F. Holding the patient down to prevent injury
This is an incorrect instruction. Holding the patient down during a seizure can cause injury to both the patient and the person restraining them. It is important to create a safe environment by removing hazards and guiding the patient away from dangerous objects or situations, but holding them down is not appropriate.
Similar Questions
A nurse is providing discharge instruction to a client who has hypertension that has resulted in a transient ischemic attack (TIA). Which of the following information should the nurse discuss with the client regarding blood pressure (BP) management?
A. The client should maintain systolic BP between 120 and 129 mm Hg.
The client should maintain systolic BP between 120 and 129 mm Hg.This is an appropriate recommendation. The American Heart Association (AHA) guidelines recommend maintaining systolic BP below 130 mm Hg to reduce the risk of stroke and other cardiovascular events in individuals with a history of stroke or TIA.
B. The client should maintain systolic BP between 130 and 135 mm Hg.
The client should maintain systolic BP between 130 and 135 mm Hg.This is slightly above the recommended range. While systolic BP below 135 mm Hg is generally recommended for individuals with a history of stroke or TIA, a range of 130-135 mm Hg may still be acceptable based on individual patient factors and risk assessments.
C. The client should maintain systolic BP between 136 and 140 mm Hg.
The client should maintain systolic BP between 136 and 140 mm Hg. This is above the recommended range. Systolic BP between 136 and 140 mm Hg may be considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.
D. The client should maintain systolic BP between 141 and 145 mm Hg.
The client should maintain systolic BP between 141 and 145 mm Hg.This is above the recommended range. Systolic BP above 140 mm Hg is generally considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.
E. Note the time the seizure started
Full Explanation
A. The client should maintain systolic BP between 120 and 129 mm Hg.
This is an appropriate recommendation. The American Heart Association (AHA) guidelines recommend maintaining systolic BP below 130 mm Hg to reduce the risk of stroke and other cardiovascular events in individuals with a history of stroke or TIA.
B. The client should maintain systolic BP between 130 and 135 mm Hg.
This is slightly above the recommended range. While systolic BP below 135 mm Hg is generally recommended for individuals with a history of stroke or TIA, a range of 130-135 mm Hg may still be acceptable based on individual patient factors and risk assessments.
C. The client should maintain systolic BP between 136 and 140 mm Hg.
This is above the recommended range. Systolic BP between 136 and 140 mm Hg may be considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.
D. The client should maintain systolic BP between 141 and 145 mm Hg.
This is above the recommended range. Systolic BP above 140 mm Hg is generally considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.
Which signs and symptoms characterize expressive aphasia?
A. Difficulty initiating speech
Difficulty initiating speechThis is a characteristic symptom of expressive aphasia. Individuals with expressive aphasia have difficulty initiating speech and may produce speech that is slow, effortful, and lacking in grammatical structure.
B. Difficulty understanding the written and spoken word
Difficulty understanding the written and spoken wordThis symptom is not typically associated with expressive aphasia. Instead, difficulty understanding language, both written and spoken, is more commonly seen in receptive aphasia, also known as Wernicke's aphasia.
C. Total inability to communicate
Total inability to communicate While expressive aphasia can severely impair verbal communication, it does not result in a total inability to communicate. Individuals with expressive aphasia may still be able to communicate to some extent using nonverbal means, gestures, or writing.
D. Stuttering and spitting
Stuttering and spittingStuttering and spitting are not characteristic symptoms of expressive aphasia. Stuttering is a speech disorder characterized by interruptions in the flow of speech, while spitting is not typically associated with aphasia.
Full Explanation
A. Difficulty initiating speech
This is a characteristic symptom of expressive aphasia. Individuals with expressive aphasia have difficulty initiating speech and may produce speech that is slow, effortful, and lacking in grammatical structure.
B. Difficulty understanding the written and spoken word
This symptom is not typically associated with expressive aphasia. Instead, difficulty understanding language, both written and spoken, is more commonly seen in receptive aphasia, also known as Wernicke's aphasia.
C. Total inability to communicate
While expressive aphasia can severely impair verbal communication, it does not result in a total inability to communicate. Individuals with expressive aphasia may still be able to communicate to some extent using nonverbal means, gestures, or writing.
D. Stuttering and spitting
Stuttering and spitting are not characteristic symptoms of expressive aphasia. Stuttering is a speech disorder characterized by interruptions in the flow of speech, while spitting is not typically associated with aphasia.
On admission to the emergency department, a patient with a C5 compression fracture can move only his head and has flaccid paralysis of all extremities. The distraught family asks if the paralysis is permanent. Which is the best response by the nurse?
A. "It is too early to tell. When the spinal shock subsides, we will know more."
"It is too early to tell. When the spinal shock subsides, we will know more."This response is appropriate. Spinal shock can initially obscure the extent of neurological injury, and it may take time for the full extent of the injury to become apparent. By acknowledging this and suggesting that more information will be available once spinal shock subsides, the nurse provides a realistic perspective without prematurely predicting the outcome.
B. "You should talk to your physician about things of that nature."
"You should talk to your physician about things of that nature."This response may come across as dismissive or evasive. While it is true that the physician ultimately determines the patient's prognosis, the family may be seeking reassurance and guidance from the nurse as well.
C. "No. Significant recovery of function should occur in a few days."
"No. Significant recovery of function should occur in a few days." This response is overly optimistic and potentially misleading. While some improvement may occur in the days following a spinal cord injury, significant recovery of function within a few days is unlikely, especially in cases of flaccid paralysis of all extremities.
D. "Yes. In all likelihood, the paralysis is probably permanent."
This response is overly pessimistic and lacks sensitivity. It may unnecessarily distress the family and extinguish hope for the patient's recovery.
Full Explanation
A. "It is too early to tell. When the spinal shock subsides, we will know more."
This response is appropriate. Spinal shock can initially obscure the extent of neurological injury, and it may take time for the full extent of the injury to become apparent. By acknowledging this and suggesting that more information will be available once spinal shock subsides, the nurse provides a realistic perspective without prematurely predicting the outcome.
B. "You should talk to your physician about things of that nature."
This response may come across as dismissive or evasive. While it is true that the physician ultimately determines the patient's prognosis, the family may be seeking reassurance and guidance from the nurse as well.
C. "No. Significant recovery of function should occur in a few days."
This response is overly optimistic and potentially misleading. While some improvement may occur in the days following a spinal cord injury, significant recovery of function within a few days is unlikely, especially in cases of flaccid paralysis of all extremities.
D. "Yes. In all likelihood, the paralysis is probably permanent."
This response is overly pessimistic and lacks sensitivity. It may unnecessarily distress the family and extinguish hope for the patient's recovery.