A client is having a tonic-clonic seizure. What should the nurse do first?
Elevate the head of the bed.
Restrain the client's arms and legs.
Place a tongue blade in the client's mouth.
Take measures to prevent injury.
The Correct Answer is D
A. Elevate the head of the bed: Elevating the head of the bed is not the priority during a seizure. The primary concern is ensuring the client's safety by preventing injury.
B. Restrain the client's arms and legs: Restraining a client during a seizure is not advised, as it can cause injury. Instead, the focus should be on protecting the client from harm.
C. Place a tongue blade in the client's mouth: Placing anything in the client’s mouth during a seizure is contraindicated, as it can lead to airway obstruction or injury.
D. Take measures to prevent injury: The priority during a seizure is to protect the client from injury by ensuring a safe environment, such as padding the head and moving any dangerous objects away.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Random, rapid growth of the tumor: Benign tumors generally grow slowly and are less likely to invade nearby tissues. Rapid growth is more characteristic of malignant tumors.
B. Cells colonizing to distant body parts: Benign tumors do not metastasize to distant parts of the body; this is a feature of malignant tumors.
C. Tumor pressure against normal tissues: Even though benign tumors do not invade other tissues, they can still cause problems by pressing against surrounding normal tissues, potentially leading to significant functional issues depending on their location.
D. Emission of abnormal proteins: Abnormal protein emission is more relevant to malignancies that may cause paraneoplastic syndromes rather than benign tumors.
Correct Answer is B
Explanation
A. The client can obtain and maintain employment. While obtaining and maintaining employment can be a positive outcome, it does not specifically address the control of aggressive behaviors which are the focus here.
B. The client is free from aggressive behaviors. Being free from aggressive behaviors directly reflects successful treatment of aggressive symptoms in schizophrenia. This outcome specifically addresses the primary concern.
C. The client utilizes relaxation techniques. Utilizing relaxation techniques can be part of managing symptoms but does not directly measure the control of aggressive behaviours.
D. The client maintains healthy relationships with others. Maintaining healthy relationships is a positive outcome, but it is a broader goal and does not directly indicate control of aggressive behaviours.
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