A nurse enters a client's room and finds the client experiencing a seizure on the floor. Which of the following actions should the nurse take?
Place a pillow under the client's head.
Gently restrain the client's arms.
Administer a muscle relaxant.
Insert a tongue blade.
The Correct Answer is A
A. Place a pillow under the client's head. Placing a pillow under the client's head is appropriate as it helps protect the client's head from injury during the seizure. Providing cushioning can reduce the risk of head trauma, which is a common concern during seizures.
B. Gently restrain the client's arms. Gently restraining the client's arms is not recommended during a seizure, as it can lead to injury. Restraining movements can also increase the risk of injury to both the client and the caregiver. Instead, the nurse should allow the seizure to progress without interference.
C. Administer a muscle relaxant. Administering a muscle relaxant is not appropriate during a seizure. The nurse should not medicate the client until the seizure has stopped and the healthcare provider has assessed the situation. Immediate management focuses on safety rather than medication.
D. Insert a tongue blade. Inserting a tongue blade or any object into the client's mouth is dangerous and not recommended. This can cause oral injury, broken teeth, or airway obstruction. The nurse should ensure the area is clear of hazards and allow the seizure to occur without attempting to prevent movements.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Position the car seat at a 90° angle." Positioning the car seat at a 90° angle is not recommended. The car seat should be reclined at an angle of 30 to 45 degrees to ensure that the infant's head does not flop forward, which can obstruct the airway.
B. "Keep the airbag on if the car seat is in the front seat." Keeping the airbag on when a car seat is in the front seat is unsafe. It is recommended to place the car seat in the back seat, as the force of an airbag deploying can be harmful to a child in a car seat.
C. "Put a small cushion under the newborn's head for support." Placing a cushion under the newborn's head is not recommended, as it can interfere with the proper positioning of the car seat and compromise the safety of the infant. The car seat is designed to provide support without additional cushions.
D. "Place the shoulder harnesses at the level of the infant's shoulders." Placing the shoulder harnesses at the level of the infant's shoulders is the correct practice. The harnesses should be positioned snugly at or just above the shoulders for optimal safety, ensuring that the infant is securely restrained in the car seat.
Correct Answer is ["A","B","D","E"]
Explanation
A. Communicate advance directives status via the medical record and shift report. The nurse is responsible for ensuring that all members of the healthcare team are aware of the client’s advance directives. Documenting this information in the medical record and shift report helps guide care in accordance with the client’s wishes.
B. Provide the client with written information about advance directives. Clients have the right to receive information about advance directives, including living wills and do-not-resuscitate (DNR) orders. The nurse should provide educational materials to help the client make informed decisions.
C. Inform the client that an advance directive discontinues further care. An advance directive does not automatically discontinue all medical care. It provides instructions regarding specific interventions the client wishes to accept or decline, such as resuscitation, mechanical ventilation, or artificial nutrition. The nurse should clarify this to avoid misconceptions.
D. Instruct the client that an advance directive is a legal document and must be honored by care providers. Advance directives are legally binding documents that must be followed by healthcare providers. The nurse should reinforce that the client’s wishes, as stated in the directive, will be respected.
E. Document that the provider discussed do-not-resuscitate status with the client. Proper documentation is essential to ensure the client's preferences regarding resuscitation and end-of-life care are acknowledged and followed. The nurse should record discussions regarding advance directives in the medical record.
F. Initiate a power of attorney for health care document. The nurse does not have the authority to initiate a power of attorney for health care. The client must complete this legal document independently or with legal assistance, and it typically requires notarization or witness signatures. The nurse can provide information about it but cannot create or execute it on the client’s behalf.
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