a home health nurse is providing teaching to the family of a client who has a seizure disorder which of the following interventions should the nurse i

ATI RN

ATI Capstone Adult Medical Surgical Assessment 1

1. A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following interventions should the nurse include in the teaching?

A. Keep a padded tongue depressor near the bedside
B. Place a pillow under the client's head during a seizure
C. Administer diazepam intravenously at the onset of seizures
D. Position the client on their side during a seizure

Correct answer: D

Rationale: The correct intervention for a client who has a seizure disorder is to position the client on their side during a seizure. This helps to prevent aspiration and ensures a patent airway. Keeping a padded tongue depressor near the bedside (Choice A) is not recommended as it can cause injury during a seizure. Placing a pillow under the client's head during a seizure (Choice B) is also not advised as it can obstruct the airway. Administering diazepam intravenously at the onset of seizures (Choice C) is not typically done at home without healthcare provider direction.

2. What are the dietary recommendations for a patient with GERD?

A. Avoid mint and spicy foods
B. Eat large meals before bedtime
C. Consume liquids with meals
D. Avoid NSAIDs

Correct answer: A

Rationale: The correct answer is to avoid mint and spicy foods for a patient with GERD. These foods can increase gastric acid secretion and worsen symptoms of GERD. Choice B is incorrect because eating large meals before bedtime can exacerbate GERD symptoms due to increased gastric pressure when lying down. Choice C is also incorrect as consuming liquids with meals can lead to increased gastric distention, potentially triggering GERD symptoms. Choice D, avoiding NSAIDs, though important for some patients with GERD due to their potential to irritate the stomach lining, is not a general dietary recommendation for all GERD patients.

3. What are the adverse effects of radiation after a mastectomy?

A. S3 heart sound, fatigue
B. Pulselessness in the affected extremity
C. SOB and JVD
D. Localized pain, swelling, erythema

Correct answer: A

Rationale: The correct answer is A: S3 heart sound, fatigue. Radiation after a mastectomy can lead to fatigue and symptoms of heart failure, such as the presence of an S3 heart sound. Choices B, C, and D are incorrect. Pulselessness in the affected extremity would be more relevant to vascular complications, shortness of breath (SOB) and jugular venous distention (JVD) could indicate cardiac or respiratory issues unrelated to radiation, and localized pain, swelling, and erythema are more characteristic of a local inflammatory response rather than the systemic effects of radiation post-mastectomy.

4. A client is scheduled for an electroencephalogram (EEG) and a nurse is providing teaching. Which of the following statements by the client indicates an understanding of the teaching?

A. I should not wash my hair prior to the procedure.
B. I will receive a sedative 1 hour before the procedure.
C. I should avoid eating prior to the procedure.
D. I will be exposed to flashes of light during the procedure.

Correct answer: D

Rationale: The correct answer is D. The nurse should inform the client that flashes of light or pictures are often used during the procedure to assess the brain's response to stimuli. Choices A, B, and C are incorrect because washing hair, receiving a sedative, and avoiding eating are not directly related to the EEG procedure.

5. What dietary changes should be implemented for a patient with GERD?

A. Avoid mint and spicy foods
B. Eat large meals before bedtime
C. Consume liquids with meals
D. Drink milk as a snack

Correct answer: A

Rationale: The correct answer is A: Avoid mint and spicy foods. Patients with GERD should avoid mint and spicy foods because they can increase gastric acid production, exacerbating symptoms. Choice B is incorrect because eating large meals before bedtime can worsen GERD symptoms due to lying down with a full stomach. Choice C is incorrect as consuming liquids with meals can lead to increased pressure on the lower esophageal sphincter, promoting acid reflux. Choice D is also incorrect as drinking milk as a snack is not recommended for GERD patients, as it may temporarily soothe symptoms but can ultimately stimulate acid production.