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 B
Explanation
An exercise stress test is a diagnostic procedure that measures the heart's response to physical activity. The client is instructed to walk on a treadmill or pedal a stationary bike while their heart rate, blood pressure, and electrocardiogram are monitored. The test can help detect coronary artery disease, arrhythmias, or other cardiac problems.
The client should follow certain guidelines before the test, such as:
- Avoiding caffeine, nicotine, alcohol, and stimulants for at least 4 hours before the test, as they can affect the heart rate and blood pressure.
- Fasting for at least 2 hours before the test, as eating can affect the blood flow to the heart.
- Getting adequate rest and sleep the night before the test, as fatigue can affect the performance and results of the test.
- Wearing comfortable clothing and shoes that are suitable for exercise.
- Informing the provider of any medications they are taking, as some medications may need to be withheld or adjusted before the test, such as beta blockers, calcium channel blockers, nitrates, or antiarrhythmics. These medications can affect the heart rate and blood pressure and interfere with the interpretation of the test results.
Therefore, the comment made by the client that indicates a need for further teaching is "I'll take my heart medications the morning of my test." The client should consult with their provider about whether they should take their heart medications or not before the test. The other comments made by the client are appropriate and indicate that they understand the pre-test instructions.
Correct Answer is B
Explanation
Planning to slow down if tired the day after exercising is a statement that indicates the client understands the importance of pacing activities and avoiding overexertion, which can worsen heart failure symptoms.
a. "I should use naproxen to manage discomfort." is not correct, as naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause fluid retention, increase blood pressure, and worsen heart failure. The client should avoid NSAIDs and use other analgesics, such as acetaminophen, unless contraindicated.
c. "I will read food labels and limit my sodium to 4 grams per day." is not appropriate, as 4 grams of sodium per day is too high for a client who has congestive heart failure. The client should limit sodium intake to 2 grams or less per day, as sodium can cause fluid retention and increase the workload of the heart.
d. "I will take my diuretic before sleep and drink fluids during the day." is not advisable, as taking a diuretic before sleep can cause nocturia and disrupt the sleep cycle, which can affect the quality of life and cardiac function. The
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