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.

Answer and Explanation

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

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Correct Answer is C

Explanation

Ventricular gallop is another name for the S3 sound, which is a low-pitched sound heard at the end of diastole, just after the S2 sound. It is caused by the rapid filling of the ventricles and the vibration of the ventricular walls.

Closure of the pulmonic valve is one of the components of the S2 sound, which is a high-pitched sound heard at the end of the systole, just before the S1 sound. It is caused by the closure of the semilunar valves (pulmonic and aortic).

Closure of the mitral valve is one of the components of the S1 sound, which is a high-pitched sound heard at the beginning of systole, just after the S2 sound. It is caused by the closure of the atrioventricular valves (mitral and tricuspid).

d. Atrial gallop is another name for the S4 sound, which is a low-pitched sound heard at the end of diastole, just before the S1 sound. It is caused by atrial contraction and increased resistance to ventricular filling.

A. "These tests help determine the degree of damage to the heart tissues." B. "These tests will enable the provider to determine the heart structure and mobility of the heart valves." C. "Cardiac enzymes will identify the location of the MI." D. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion."

Correct Answer is A

Explanation

The nurse should explain that cardiac enzyme studies measure the levels of certain enzymes, such as troponin, creatine kinase, and lactate dehydrogenase, that are released into the bloodstream when the heart muscle is damaged by an MI. These tests help determine the degree of damage to the heart tissues, as well as the timing and severity of the MI.

"These tests will enable the provider to determine the heart structure and mobility of the heart valves." is wrong because cardiac enzyme studies do not provide information about the heart structure and mobility of the heart valves. Other tests, such as echocardiography or cardiac catheterization, may be used for this purpose.

"Cardiac enzymes will identify the location of the MI." is wrong because cardiac enzyme studies do not indicate the specific location of the MI within the heart. Other tests, such as electrocardiography or coronary angiography, may be used for this purpose.

"Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." is wrong because cardiac enzyme studies do not directly assess the presence of pulmonary congestion, which is a complication of heart failure. Other signs and symptoms, such as dyspnea, crackles, and chest x-ray findings, may be used for this purpose.

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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?

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Naxlex Comprehensive Predictor Exams

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