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 D

Explanation

Taking one tablet at the first indication of chest pain is the correct way to use SL nitroglycerin tablets, as they are fast- acting and can relieve anginal symptoms within minutes. The client should place the tablet under the tongue and let it dissolve.

Taking this medication after each meal and at bedtime is not appropriate, as SL nitroglycerin tablets are not meant for routine or prophylactic use, but only for acute episodes of angina.

Taking one tablet every 15 min during an acute attack is not correct, as the client should not exceed three doses in 15 min. If the pain is not relieved after three doses, the client should seek emergency medical attention.

Taking this medication with 8 ounces of water is not necessary, as SL nitroglycerin tablets do not need to be swallowed or washed down with water. They should be dissolved under the tongue for optimal absorption.

A. Hold the client's arms and legs from moving. B. Place the client back in bed. C. Place the client on his side. D. Insert a tongue blade in the client's mouth.

Correct Answer is C

Explanation

Placing the client on his side is an essential action to take during a seizure, as it can prevent airway obstruction and aspiration. The client should be placed on his side, preferably in a lateral recumbent position, to allow saliva and secretions to drain from the mouth.

Holding the client's arms and legs from moving is not appropriate, as it can cause injury, increase agitation, or prolong the seizure. The client should be allowed to move freely during a seizure, but supported and guided away from hazards.

Placing the client back in bed is not necessary, as it can cause harm or delay care. The client should be left on the ﬂoor, unless it is unsafe or uncomfortable, and padded with pillows or blankets to protect from injury.

Inserting a tongue blade in the client's mouth is not advisable, as it can cause oral trauma, choking, or damage to the teeth. The client should not have anything inserted into his mouth during a seizure, as he cannot swallow or bite his tongue. The nurse should ensure that the client's airway is clear and patent.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has angina pectoris about starting therapy with SL nitroglycerin tablets. The nurse should include which of the following instructions regarding how to take the medication?

Correct Answer is D

Explanation

A nurse enters a client's room and finds the client on the ﬂoor having a seizure. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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