Page 2061 - Saunders Comprehensive Review For NCLEX-RN

giving expert care and positive feedback to the client, and encouraging relaxation
and distraction. The family can become involved with selected care activities and
provide diversion for the client as well.
Test-Taking Strategy: Focus on the subject, helping a client cope with illness.
Option 1 should be eliminated first, because it is not practical to think that the client
would want full control over all care decisions. The client who is paralyzed cannot
participate in active range of motion, which eliminates option 2. From the remaining
options, the correct option is more beneficial in helping the client cope.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Caring
Content Area: Adult Health: Neurological
Health Problem: Adult Health: Neurological: Guillain-Barré syndrome
Priority Concepts: Caregiving; Coping
Reference: Ignatavicius, Workman, Rebar (2018), pp. 916-917.

719. Answer: 2

Rationale: The limbic system is responsible for feelings (affect) and emotions.
Calculation ability and knowledge of current events relate to function of the frontal
lobe. The cerebral hemispheres, with specific regional functions, control orientation.
Recall of recent events is controlled by the hippocampus.
Test-Taking Strategy: Focus on the subject, neurological deficit of the limbic
system. It is necessary to recall that the limbic system is responsible for feelings and
emotions to direct you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Neurological
Health Problem: N/A
Priority Concepts: Clinical Judgment; Intracranial Regulation
Reference: Lewis et al. (2017), pp. 79, 1298.

720. Answer: 1, 2, 5, 6

Rationale: Seizure precautions may vary from agency to agency, but they
generally have some common features. Usually, an airway, oxygen, and suctioning
equipment are kept available at the bedside. The side rails of the bed are padded,
and the bed is kept in the lowest position. The client has an intravenous access in
place to have a readily accessible route if antiseizure medications must be
administered, and as part of the routine assessment the nurse should be checking
patency of the catheter. The use of padded tongue blades is highly controversial, and
they should not be kept at the bedside. Forcing a tongue blade into the mouth during
a seizure more likely will harm the client who bites down during seizure activity.
Risks include blocking the airway from improper placement, chipping the client’s
teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura
before the seizure, it may give the nurse enough time to place an oral airway before

2061