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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pivotal Joint (Radius-Ulnar Joint) –A pivot joint allows for rotation around a single axis. The joint between the radius and ulna at the elbow allows the forearm to rotate (pronation/supination). This is not a ball-and-socket joint because it does not allow movement in multiple planes.
B. A ball-and-socket joint allows for the greatest range of motion in multiple directions, including flexion, extension, abduction, adduction, and rotation. Examples are the hip joint (femur-acetabulum) and shoulder joint (humerus-glenoid cavity).
C. A hinge joint allows movement in only one plane (like a door hinge) with flexion and extension. Examples are the knee joint (tibia-femur) and elbow joint (humerus-ulna) function as hinge joints. It is not a ball-and-socket joint because it does not allow rotation or movement in multiple planes.
D. A condyloid (ellipsoidal) joint allows movement in two planes (flexion/extension and abduction/adduction), but no rotation. Examples are the wrist joint (radiocarpal joint) allows side-to-side and up-and-down movements but lacks full rotation.
Correct Answer is A
Explanation
A. Inject 15 units of air into the regular insulin vial. When mixing NPH and regular insulin, air is first injected into both vials without touching the solution. After injecting air into the NPH vial, the next step is to inject air into the regular insulin vial to maintain proper vial pressure before withdrawing the dose.
B. Place the cap over the needle. Recapping needles increases the risk of needlestick injuries and is not necessary during the insulin preparation process. The needle should remain uncapped until both insulins are drawn and the injection is ready.
C. Withdraw 10 units of NPH insulin. Regular insulin should be drawn first to prevent contamination with NPH insulin. Since NPH is a cloudy suspension and regular insulin is clear, drawing regular insulin first ensures that the short-acting insulin remains unaltered.
D. Verify the dosage with another nurse. While verifying high-risk medications like insulin is important, the appropriate step after injecting air into the NPH vial is to proceed with injecting air into the regular insulin vial before withdrawing any insulin.
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