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

Cytotoxic hypersensitivity is a type of hypersensitivity that involves the production of IgG or IgM antibodies that bind to antigens on the surface of cells, leading to cell destruction by complement activation or antibody-dependent cellular cytotoxicity. Myasthenia gravis is an example of a cytotoxic hypersensitivity, as it is caused by autoantibodies that target the acetylcholine receptors on the muscle cells, impairing neuromuscular transmission and causing muscle weakness.

Delayed hypersensitivity is a type of hypersensitivity that involves the activation of T cells and macrophages, leading to inﬂammation and tissue damage after several hours or days of exposure to an antigen. Examples of delayed hypersensitivity include contact dermatitis, tuberculin skin test, and transplant rejection.

Immediate hypersensitivity is a type of hypersensitivity that involves the production of IgE antibodies that bind to mast cells or basophils, leading to degranulation and release of histamine and other mediators, causing anaphylaxis, urticaria, or allergic rhinitis within minutes of exposure to an antigen.

Immune complex-mediated hypersensitivity is a type of hypersensitivity that involves the formation of antigen- antibody complexes that deposit in tissues or blood vessels, leading to complement activation and inﬂammation, causing vasculitis, glomerulonephritis, or serum sickness within hours or days of exposure to an antigen.

A. Thick, deformed toenails B. Edema C. Dependent rubor D. Hair loss

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.

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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 D

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Correct Answer is B

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