A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?
Place a pillow under the client's head.
Gently restrain the client's extremities.
Apply a face mask for oxygen administration.
Insert a padded tongue blade into the client's mouth.
The Correct Answer is A
- Place a pillow under the client's head.
The nurse should place a pillow under the client's head to protect it from injury during the seizure. The nurse should also loosen any tight clothing, remove any objects that could harm the client, and maintain a patent airway.
- Gently restrain the client's extremities is wrong because it can cause injury to the client or the nurse. The nurse should not restrain or interfere with the client's movements during the seizure, but rather ensure a safe environment and observe the seizure activity.
- Apply a face mask for oxygen administration is wrong because it can be dislodged by the client's movements and pose a choking hazard. The nurse should not atempt to insert anything into the client's mouth or nose during the seizure, but rather provide oxygen by nasal cannula after the seizure if needed.
Insert a padded tongue blade into the client's mouth is wrong because it can damage the client's teeth, gums, or tongue, or cause aspiration or airway obstruction. The nurse should not atempt to insert anything into the client's mouth or nose during the seizure, but rather turn the client to a side-lying position after the
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Frothy sputum is a sign of left-sided heart failure, due to the pulmonary congestion and impaired gas exchange. The sputum may be pink-tinged or blood-streaked, indicating pulmonary edema.
a. Dependent edema is more likely to be seen in clients who have right-sided heart failure, due to the increased venous pressure and fluid retention. The edema is usually symmetrical and affects the lower extremities, abdomen, and sometimes the face.
c. Nocturnal polyuria is not a specific finding of left-sided heart failure, but it may occur in clients who have renal impairment, diabetes mellitus, or diuretic therapy.
d. Jugular distention is another sign of right-sided heart failure, due to the increased central venous pressure and backward flow of blood into the superior vena cava. It is visible as a bulging of the neck veins, especially when the client is in a semi-Fowler's position.
Correct Answer is C
Explanation
Swallowing the capsules whole is the correct way to take nitroglycerin oral, sustained-release capsules, as they are designed to release the medication slowly and steadily over time. The client should not crush, chew, or open the capsules, as this can alter the absorption and effectiveness of the medication.
Taking 1 capsule at the onset of anginal pain is not appropriate, as nitroglycerin oral, sustained-release capsules are not meant for acute episodes of angina, but for long-term prevention and management. The client should use a fast-acting form of nitroglycerin, such as sublingual tablets or spray, to relieve anginal pain.
Taking the medication with meals is not necessary, as nitroglycerin oral, sustained-release capsules can be taken with or without food. However, the client should take the medication at regular intervals and around the same time each day.
Stopping taking the medication if side effects are troublesome is not advisable, as nitroglycerin oral, sustained-release capsules can cause withdrawal symptoms and rebound angina if discontinued abruptly. The client should consult with the provider before stopping or changing the dose of the medication. The client should also report any severe or persistent side effects, such as headache, dizziness, hypotension, or tachycardia.
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