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 is the most likely cause of continuous bubbling in the water seal chamber of a chest tube?

A. An air leak
B. A blockage in the chest tube
C. Normal chest tube function
D. Drainage from the chest tube

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube usually indicates an air leak. An air leak can disrupt the negative pressure required for the chest tube to function properly, leading to inadequate drainage and potential complications. A blockage in the chest tube would typically result in decreased or absent drainage rather than continuous bubbling. Normal chest tube function does not involve continuous bubbling in the water seal chamber. Drainage from the chest tube may lead to fluid moving into the drainage system, but it would not cause continuous bubbling in the water seal chamber.

3. What are the expected symptoms of a thrombotic stroke?

A. Gradual loss of function on one side of the body
B. Sudden loss of consciousness
C. Severe headache and confusion
D. Loss of sensation in the affected limb

Correct answer: A

Rationale: The correct answer is A: 'Gradual loss of function on one side of the body.' In a thrombotic stroke, a clot blocks a cerebral artery, leading to a gradual onset of symptoms such as weakness, numbness, or paralysis on one side of the body. Choice B, 'Sudden loss of consciousness,' is more characteristic of a hemorrhagic stroke. Choice C, 'Severe headache and confusion,' are often associated with subarachnoid hemorrhage rather than thrombotic stroke. Choice D, 'Loss of sensation in the affected limb,' is not a typical symptom pattern for a thrombotic stroke, which usually presents with motor deficits.

4. What dietary recommendations should be given to a patient with GERD?

A. Avoid mint and spicy foods
B. Eat large meals before bed
C. Increase fluid intake during meals
D. Drink milk as a snack

Correct answer: A

Rationale: The correct dietary recommendation for a patient with GERD is to avoid mint and spicy foods. These foods can trigger symptoms of GERD and lead to acid reflux. Choice B is incorrect because eating large meals before bed can exacerbate GERD symptoms by increasing the likelihood of acid reflux during sleep. Choice C is incorrect as increasing fluid intake during meals can worsen GERD symptoms by distending the stomach, leading to increased pressure on the lower esophageal sphincter. Choice D is also incorrect because while milk may provide temporary relief for some individuals, it is not a recommended long-term solution for managing GERD.

5. A patient who experienced an acute episode of gastritis should avoid which type of foods?

A. Avoid foods high in potassium
B. Avoid foods high in sodium
C. Increase exercise to reduce stress
D. Drink milk as a snack

Correct answer: A

Rationale: The correct answer is A: Avoid foods high in potassium. Potassium-rich foods can exacerbate gastritis symptoms by irritating the stomach lining. Sodium (choice B) is not directly related to gastritis symptoms. Increasing exercise (choice C) can be beneficial for overall health but may not directly impact gastritis. Drinking milk (choice D) can provide temporary relief for some individuals with gastritis due to its coating effect, but it is not a universal recommendation as it can worsen symptoms in some cases.