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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Tolerance: Tolerance occurs when an individual requires increasing amounts of a substance to achieve the same effect. This can explain why a person with a high blood alcohol level might not appear intoxicated if they have developed tolerance.

B. Addiction: Addiction is a chronic disease involving compulsive substance use. While related to tolerance, addiction itself does not specifically explain the lack of observable intoxication symptoms.

C. Alcoholism: Alcoholism is a condition involving dependency on alcohol. It can involve tolerance, but the term "alcoholism" does not specifically address the immediate observation of high alcohol levels without visible intoxication.

D. Relapse: Relapse refers to returning to substance use after a period of abstinence. It does not specifically explain the lack of visible intoxication despite high blood alcohol levels.

A. Random, rapid growth of the tumor B. Cells colonizing to distant body parts C. Tumor pressure against normal tissues D. Emission of abnormal proteins

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.

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A client is having a tonic-clonic seizure. What should the nurse do first?

Nursing Test Bank

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