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 B

Explanation

Edema is a common finding in clients who have chronic venous insufficiency, due to the impaired venous return and increased capillary pressure. The edema is usually worse at the end of the day and improves with elevation.

a. Thick, deformed toenails are more likely to be seen in clients who have fungal infections or peripheral arterial disease, not chronic venous insufficiency.

c. Dependent rubor is a sign of peripheral arterial disease, not chronic venous insufficiency. It is a reddish color of the lower extremities that occurs when they are lowered and disappears when they are elevated.

d. Hair loss is another sign of peripheral arterial disease, not chronic venous insufficiency. It is caused by the reduced blood supply to the hair follicles.

A. Turn the client's head to the side. B. Check the client's motor strength. C. Document the time the seizure began. D. Loosen the clothing around the client's waist.

Correct Answer is A

Explanation

Turn the client's head to the side.

The nurse should turn the client's head to the side first to prevent aspiration of oral secretions and maintain a patent airway. This is the priority action according to the airway, breathing, and circulation (ABC) principle.

Check the client's motor strength is wrong because it is not the priority action and it is not feasible during a seizure. The nurse should check the client's motor strength after the seizure to assess for any neurological deficits or postictal weakness.

Document the time the seizure began is wrong because it is not the priority action and it can be done later. The nurse should document the time, duration, type, and characteristics of the seizure, but only after ensuring the client's safety and well-being.

Loosen the clothing around the client's waist is wrong because it is not the priority action and it may not be necessary. The nurse should loosen any tight clothing that could impair breathing or circulation, but only after securing the airway and protecting the head from injury.

Turn the client's head to the side.

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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

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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