A nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic-clonic seizure. Which of the following interventions should the nurse take?

Insert a padded tongue blade into the client's mouth.

Place a pillow under the client's head.

Gently restrain the client's extremities.

Keep the client in a supine position.

Answer and Explanation

The Correct Answer is B

A. Insert a padded tongue blade into the client's mouth.

This intervention is not recommended. Placing any object, including a padded tongue blade, into the mouth of someone experiencing a seizure poses a risk of injury, such as biting the tongue or breaking teeth. It can also obstruct the airway and increase the risk of aspiration. Therefore, inserting anything into the client's mouth during a seizure is contraindicated.

B. Place a pillow under the client's head.

Placing a pillow under the client's head can help prevent head injury by providing cushioning and support. It can also help maintain the client's airway and reduce the risk of aspiration. Therefore, this intervention is appropriate and helps ensure the client's safety during the seizure.

C. Gently restrain the client's extremities.

Restraining the client's extremities is not recommended during a seizure. It can increase the risk of injury, such as fractures or dislocations, and may exacerbate muscle contractions. It's important to allow the client's movements to occur naturally while taking measures to ensure their safety, such as removing nearby objects and providing a safe environment.

D. Keep the client in a supine position.

It is essential to ensure that the client's head is turned to the side (recovery position) to prevent aspiration and allow for drainage of oral secretions. Additionally, the nurse should remove any nearby objects that could pose a risk of injury during the seizure.

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Correct Answer is A

Explanation

A. B6 (Pyridoxine):

Vitamin B6, also known as pyridoxine, is known to reduce the therapeutic effects of levodopa. It competes with levodopa for absorption in the gastrointestinal tract and can decrease the amount of levodopa that reaches the brain, thereby diminishing its effectiveness in treating Parkinson's disease symptoms.

B. A (Retinol):

Vitamin A, also known as retinol, is not typically associated with reducing the therapeutic effects of levodopa. Vitamin A plays important roles in vision, immune function, and cellular communication, but it does not interact with levodopa in a way that affects its therapeutic efficacy.

C. E (Alpha-Tocopherol):

Vitamin E, also known as alpha-tocopherol, is an antioxidant that plays a role in protecting cells from oxidative damage. While vitamin E supplementation is sometimes used in Parkinson's disease management for its potential neuroprotective effects, it is not known to reduce the therapeutic effects of levodopa.

D. K (Phylloquinone):

Vitamin K, also known as phylloquinone, is primarily involved in blood clotting and bone metabolism. It does not interact with levodopa in a way that reduces its therapeutic effects.

E. C (Ascorbic Acid):

Vitamin C, also known as ascorbic acid, is not known to reduce the therapeutic effects of levodopa. While vitamin C has various roles in the body, including antioxidant activity and immune function support, it does not interfere with levodopa absorption or efficacy.

A. Perform passive range of motion on each extremity. B. Monitor the client's electrolyte levels. C. Suction saliva from the client's mouth. D. Record the client's intake and output.

Correct Answer is C

Explanation

A. Perform passive range of motion on each extremity:

While passive range of motion exercises are important for preventing contractures and maintaining joint mobility in immobilized clients, they are not the highest priority in this situation. Airway management takes precedence over mobility exercises.

B. Monitor the client's electrolyte levels:

Monitoring electrolyte levels is important for overall assessment and management of the client's health, but it is not the highest priority when the client's airway and breathing are compromised.

C. Suction saliva from the client's mouth:

This is the correct answer. Suctioning saliva from the client's mouth helps maintain a clear airway and prevents aspiration. Unconscious clients are at risk for pooling of oral secretions, which can obstruct the airway and lead to respiratory complications.

D. Record the client's intake and output:

While monitoring intake and output is an essential part of nursing care, it is not the highest priority when the client's airway and breathing are compromised.

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A nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic-clonic seizure. Which of the following interventions should the nurse take?

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