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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
36 to 48 hours. Lyme disease is caused by the bacterium Borrelia burgdorferi, which is transmitted to humans through the bite of infected black-legged ticks. The tick must be attached to the skin for at least 36 to 48 hours for the bacterium to be transmitted. The nurse should advise the client to seek medical attention promptly.
Choice B is incorrect because the tick must be attached for a longer duration of time for the bacterium to be transmitted.
Choice C is incorrect because the tick must be attached for a longer duration of time for the bacterium to be transmitted.
Choice D is incorrect because the tick must be attached for a longer duration of time for the bacterium to be transmitted.
Correct Answer is A
Explanation
Giving non-prescription laxatives to a client with cirrhosis can cause severe dehydration and electrolyte imbalances, which can be life-threatening. The nurse should report this intervention immediately to the physician.
Choice B is incorrect because measuring abdominal girth is a standard nursing intervention for clients with cirrhosis to assess for ascites.
Choice C is incorrect because asking the client about food intake is a standard nursing intervention for assessing nutritional status.
Choice D is incorrect because checking for signs of hepatic encephalopathy is a standard nursing intervention for clients with cirrhosis.
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