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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Orthostatic hypotension:
Orthostatic hypotension, a sudden drop in blood pressure when standing up, is a potential adverse effect of levodopa therapy. This can lead to dizziness and increase the risk of falls, thus supporting the nursing diagnosis Risk for Injury.
B. Nausea and vomiting:
Nausea and vomiting are common side effects of levodopa therapy. While they can cause discomfort and dehydration, they are less directly related to the risk of physical injury compared to orthostatic hypotension.
C. Anorexia and depression:
Anorexia (loss of appetite) and depression can occur as adverse effects of levodopa therapy. While they can affect the patient's overall well-being and quality of life, they are not directly associated with an increased risk of physical injury.
D. Tachycardia and palpitations:
Tachycardia (rapid heart rate) and palpitations are less common adverse effects of levodopa therapy. While they may indicate cardiovascular issues, they are not typically associated with a direct risk of physical injury.
Correct Answer is ["15"]
Explanation
To calculate the dose of amantadine for a client with parkinsonism, the nurse needs to use the following formula:
Dose (mL) = Ordered dose (mg) / Concentration (mg/mL).
In this case, the ordered dose is 150 mg and the concentration is 50 mg/5 mL. Therefore, the dose in mL is:
Dose (mL) = 150 mg / (50 mg/5 mL)
Dose (mL) = 150 mg x (5 mL/50 mg)
Dose (mL) = 15 mL
The nurse should round the answer to the nearest whole number, which is 15 mL. The nurse should administer 15 mL of amantadine oral solution to the client.
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