A client that the nurse is caring for experiences a seizure. What would be a priority nursing action?

Restrain the client during the seizure.

Protect the client from injury.

Suction the mouth during the convulsion.

Insert a tongue blade between the teeth.

Answer and Explanation

The Correct Answer is B

During a seizure, the nurse's priority is to ensure the client's safety by protecting them from injury. The nurse should loosen any tight clothing and move furniture or objects that may harm the client. The client should be turned onto their side to prevent aspiration, and suctioning the mouth is not indicated during the seizure. Restraints are not appropriate during a seizure, and inserting a tongue blade between the teeth can cause injury.

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Free Nursing Study Resources

Correct Answer is ["B","C","D"]

Explanation

The Glasgow Coma Scale (GCS) is a tool used to assess a patient's level of consciousness following a traumatic brain injury. It is based on three categories: eye-opening, verbal response, and motor response. The tool scores a patient from 3 to 15, with 15 being the best possible score. A score of 8 or less indicates a severe brain injury. The tool does not assess thought process or cognitive ability.

A. Use aseptic technique. B. Use an applicator only once. C. Gently remove crusts around pin sites. D. Clean the site, working toward the pin. E. Obtain culture if purulent drainage.

Correct Answer is ["A","B","D","E"]

Explanation

When performing pin care, the nurse should use aseptic technique and obtain a culture if purulent drainage is present. The applicator should be used only once, and the site should be cleaned, working toward the pin. Crusts around the pin site should not be removed as this can cause trauma to the site and increase the risk of infection.

Choice C, Gently remove crusts around pin sites is not appropriate as this can cause trauma to the site and increase the risk of infection.

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A client that the nurse is caring for experiences a seizure. What would be a priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a neurological deficit. In assessing the client, the nurse will utilize the standard Glasgow Coma Scale. What will the nurse be assessing on this patient? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

When performing pin care, which of the following would be most appropriate? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

You are taking care of a client who suffers from Meniere's disease. On assessment, you note what common symptoms of this disorder? Select all that apply.

A client experiences a musculoskeletal injury that involves the structure that connects a muscle to the bone. The nurse understands that this injury involves which of the following?

Which of the following interventions would be appropriate for a client who has undergone surgery for a liver disorder and has started shivering?

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The nurse is instructing the client on frequent sensations experienced when a contrast agent is injected into the body during diagnostic studies. Which sensation is most common?

A client is suspected of having acromegaly. What definitive diagnostic testing is the most reliable for confirming acromegaly?

A client is being seen in the clinic for severe abdominal pain with nausea and vomiting. The nurse assesses the abdomen and notes an absence of bowel sounds and a very rigid abdomen. What would these assessment findings most likely indicate?