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 A
Explanation
A. Drink adequate noncaffeinated and non-alcoholic beverages: Xerostomia (dry mouth) can be alleviated by staying hydrated with noncaffeinated and non-alcoholic beverages, which help to moisten the mouth and improve comfort.
B. Take nutrient-dense foods or to combine plant-based proteins: While nutrient-dense foods are important for overall health, they do not specifically address the issue of xerostomia. Plant-based proteins do not directly impact the symptoms of dry mouth.
C. Take protein-based liquid supplements: Protein-based liquid supplements are not specifically designed to address dry mouth and may not help in alleviating xerostomia.
D. Get dental care and practice dental hygiene daily: While dental care and hygiene are important for overall oral health, they do not specifically address xerostomia. Drinking fluids is more directly helpful for managing dry mouth.
Correct Answer is A
Explanation
A. Ensure that there is a complete and functional suction system at the bedside. This is an essential precaution for clients with dysphagia because they are at high risk of aspiration. Having suction equipment ready allows for quick intervention if the client begins to choke or aspirate.
B. Position the head of the client's bed at a height of 30° to 45°. This positioning is too low for feeding. To reduce the risk of aspiration, the head of the bed should be elevated to at least 45° to 90° during feeding. Therefore, this option is less safe.
C. Provide two larger meals each day rather than three smaller meals in order to prevent fatigue. Smaller, more frequent meals are generally recommended to prevent fatigue and reduce the risk of aspiration, as larger meals can be overwhelming and increase the risk of choking.
D. Encourage the client to hold her breath while she is attempting to swallow. This is not a standard or safe practice for managing dysphagia. Safe swallowing techniques typically include ensuring the client is alert, properly positioned, and eating slowly with small bites.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.