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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. "I've been wearing the same few things every day because most of my clothes don't fit anymore." This statement reflects a common experience during pregnancy as the body changes. While it may indicate some frustration, it does not necessarily suggest difficulty accepting body image changes.
B. "Dressing up for work is a little harder now that I can't wear high heels." This statement acknowledges an adjustment in clothing choices due to pregnancy but does not indicate distress about body image. Many individuals modify their footwear for comfort and safety as pregnancy progresses.
C. "I've had to start wearing nursing bras already because my breasts are growing so much." This statement reflects awareness of bodily changes rather than difficulty accepting them. Breast enlargement is a normal part of pregnancy, and choosing appropriate clothing to accommodate these changes suggests adaptation rather than distress.
D. "When I wear high-top yoga pants, they hold my belly in so you can't even tell I'm pregnant." This statement suggests an attempt to conceal the pregnancy, which may indicate discomfort with body image changes. Actively trying to hide the pregnancy rather than embracing the natural progression of body changes can be a sign of difficulty accepting the physical transformation.

A. A client who is postoperative and has a Jackson-Pratt drain B. A client who is scheduled for surgery in 2 hr C. A client whose blood pressure is 160/90 mm Hg and reports a headache D. A client who is postoperative and reports intermittent nausea

Correct Answer is C

Explanation

A. A client who is postoperative and has a Jackson-Pratt drain. A Jackson-Pratt drain is a routine postoperative device used to prevent fluid accumulation. Unless there are signs of excessive drainage, infection, or blockage, this client does not require immediate attention.
B. A client who is scheduled for surgery in 2 hr. While preoperative preparation is important, it is not the most urgent concern. This client can be attended to after addressing more pressing clinical issues, such as potential hypertensive complications.
C. A client whose blood pressure is 160/90 mm Hg and reports a headache. A significantly elevated blood pressure with a headache may indicate a hypertensive crisis, which increases the risk of stroke or other complications. This client should be assessed immediately to determine the severity and need for intervention.
D. A client who is postoperative and reports intermittent nausea. Nausea is a common postoperative symptom and can often be managed with antiemetics and dietary modifications. It does not pose an immediate life-threatening risk compared to possible hypertensive emergencies.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 26 weeks of gestation. Which of the following statements indicates the client is having difficulty accepting the body image changes associated with pregnancy?

Correct Answer is D

Explanation

A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse see first?

Correct Answer is C

Explanation

A nurse is assisting in the care of an older adult client who was admitted from a long-term care facility. Exhibits Select the 3 findings that require immediate follow-up.

A nurse is providing change-of-shift report for a client. Which of the following information should the nurse include in the report?

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?

A nurse is assisting in the care of a client who presents to the emergency department. Exhibits Drag words from the choices below to fill in each blank in the following To further evaluate the client, the nurse anticipates the client will need dropdownanddropdown

A nurse is collecting data from a client who is in renal failure. The nurse should identify that which of the following findings is a manifestation of hyperkalemia?

A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

A nurse is reviewing laboratory findings for three clients. Which of the following laboratory results should the nurse expect for a client who has pancreatitis?

Exhibits Which of the following findings requires further action by the nurse? Select all that apply.