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.
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Related Questions
Correct Answer is C
Explanation
A. Check the client for a fecal impaction.
This intervention is important for managing autonomic dysreflexia because a fecal impaction can trigger autonomic dysreflexia by causing rectal distention. However, it is not the first action the nurse should take. Promptly addressing the immediate cause of autonomic dysreflexia is crucial to prevent complications.
B. Ensure the room temperature is warm.
This intervention is important for maintaining the client's comfort and preventing temperature-related complications. However, it is not the first action the nurse should take when suspecting autonomic dysreflexia. Immediate interventions to address the underlying cause of autonomic dysreflexia are necessary to prevent serious complications such as stroke or seizure.
C. Check the client's bladder for distention.
This is the correct action to take first. Bladder distention is one of the most common triggers of autonomic dysreflexia in individuals with spinal cord injuries. A distended bladder stimulates autonomic reflexes, leading to a sudden increase in blood pressure. Therefore, the nurse should assess the client's bladder for distention and initiate appropriate interventions such as catheterization to relieve urinary retention.
D. Raise the head of the bed.
While elevating the head of the bed can help reduce blood pressure in some situations, it is not the first action the nurse should take when suspecting autonomic dysreflexia. Elevating the head of the bed may exacerbate autonomic dysreflexia by increasing venous return and blood pressure. Therefore, addressing the underlying cause of autonomic dysreflexia, such as bladder distention, takes priority.
Correct Answer is B
Explanation
A. Excessive salivation:
Excessive salivation is not a common adverse effect of benztropine. Instead, anticholinergic medications like benztropine often cause dry mouth, which is more common than excessive salivation.
B. Difficulty voiding:
Difficulty voiding, or urinary retention, is a potential adverse effect of anticholinergic medications like benztropine. Anticholinergic drugs can cause relaxation of the detrusor muscle in the bladder, leading to urinary retention. Therefore, the nurse should instruct the client to report any difficulty or inability to urinate.
C. Diarrhea:
Diarrhea is not a common adverse effect of benztropine. Instead, anticholinergic medications like benztropine typically cause constipation due to their antimuscarinic effects on the gastrointestinal tract.
D. Slow pulse:
Slow pulse, or bradycardia, is not a common adverse effect of benztropine. Instead, anticholinergic medications like benztropine may cause tachycardia (increased heart rate) due to their effects on the autonomic nervous system.
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