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.

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Correct Answer is D

Explanation

A. Rigid abdomen. A rigid or board-like abdomen is characteristic of placental abruption, not placenta previa. Placental abruption involves premature separation of the placenta from the uterine wall, leading to significant abdominal pain and uterine tenderness. In contrast, placenta previa typically presents with painless bleeding.
B. Increased fetal movement. Fetal movement is not directly affected by placenta previa unless there is severe hemorrhage leading to fetal distress. While decreased movement in cases of significant bleeding may indicate fetal compromise, increased movement is not a typical finding.
C. Persistent uterine contractions. Placenta previa does not usually cause persistent contractions. While mild uterine irritability may occur, placenta previa is primarily characterized by painless bleeding. Persistent contractions are more commonly associated with preterm labor or placental abruption.
D. Bright red vaginal bleeding. The hallmark sign of placenta previa is painless, bright red vaginal bleeding in the second or third trimester. This occurs due to the placenta covering or being near the cervical os, leading to bleeding as the cervix begins to dilate or efface.

A. "The headaches should decrease as you get used to the medication." B. "You can discontinue the medication until the headache goes away." C. "Swallow the tablet whole to minimize your headaches." D. "You should take the medication on an empty stomach to prevent a headache."

Correct Answer is A

Explanation

A. "The headaches should decrease as you get used to the medication." Isosorbide dinitrate is a nitrate that causes vasodilation, leading to headaches due to increased blood flow and vessel expansion. These headaches are common, especially when starting therapy, but usually diminish as the body adjusts. Clients can use mild analgesics, such as acetaminophen, if needed.
B. "You can discontinue the medication until the headache goes away." Stopping isosorbide dinitrate abruptly can lead to rebound angina or worsened ischemic symptoms. Instead, the client should continue the medication as prescribed and manage headaches with analgesics or dosage adjustments as directed by the provider.
C. "Swallow the tablet whole to minimize your headaches." Isosorbide dinitrate comes in various formulations, including chewable, sublingual, and extended-release tablets. Chewable or sublingual forms are designed for rapid absorption, while extended-release tablets should be swallowed whole. However, swallowing the tablet whole does not prevent headaches, as the vasodilatory effect remains the same.
D. "You should take the medication on an empty stomach to prevent a headache." Taking isosorbide dinitrate with or without food does not significantly impact the likelihood of headaches. Food can delay absorption slightly but does not prevent vasodilation-related headaches. Adjusting the dosing schedule or using analgesics is more effective for managing this side effect.

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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?

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