A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?
Hold the client's arms and legs from moving.
Place the client back in bed.
Place the client on his side.
Insert a tongue blade in the client's mouth.
The Correct Answer is C
Placing the client on his side is an essential action to take during a seizure, as it can prevent airway obstruction and aspiration. The client should be placed on his side, preferably in a lateral recumbent position, to allow saliva and secretions to drain from the mouth.
Holding the client's arms and legs from moving is not appropriate, as it can cause injury, increase agitation, or prolong the seizure. The client should be allowed to move freely during a seizure, but supported and guided away from hazards.
Placing the client back in bed is not necessary, as it can cause harm or delay care. The client should be left on the floor, unless it is unsafe or uncomfortable, and padded with pillows or blankets to protect from injury.
Inserting a tongue blade in the client's mouth is not advisable, as it can cause oral trauma, choking, or damage to the teeth. The client should not have anything inserted into his mouth during a seizure, as he cannot swallow or bite his tongue. The nurse should ensure that the client's airway is clear and patent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
The nurse should explain that cardiac enzyme studies measure the levels of certain enzymes, such as troponin, creatine kinase, and lactate dehydrogenase, that are released into the bloodstream when the heart muscle is damaged by an MI. These tests help determine the degree of damage to the heart tissues, as well as the timing and severity of the MI.
"These tests will enable the provider to determine the heart structure and mobility of the heart valves." is wrong because cardiac enzyme studies do not provide information about the heart structure and mobility of the heart valves. Other tests, such as echocardiography or cardiac catheterization, may be used for this purpose.
"Cardiac enzymes will identify the location of the MI." is wrong because cardiac enzyme studies do not indicate the specific location of the MI within the heart. Other tests, such as electrocardiography or coronary angiography, may be used for this purpose.
"Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." is wrong because cardiac enzyme studies do not directly assess the presence of pulmonary congestion, which is a complication of heart failure. Other signs and symptoms, such as dyspnea, crackles, and chest x-ray findings, may be used for this purpose.
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