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 B
Explanation
A. A continuous seizure state in which seizures occur in rapid succession:
This describes status epilepticus, a medical emergency characterized by prolonged or continuous seizures. It is not related to the concept of an aura.
B. A sensory warning that a seizure is imminent:
This is the correct answer. An aura is a subjective sensation or symptom that acts as a warning sign that a seizure is about to occur. Auras can vary widely among individuals and may include visual, auditory, olfactory, or other sensory experiences.
C. A period of sleepiness following the seizure during which arousal is difficult:
This describes the postictal state, which occurs after a seizure. During this period, the individual may experience confusion, drowsiness, or difficulty arousing from sleep. It is not specifically related to the concept of an aura.
D. A brief loss of consciousness accompanied by staring:
This describes an absence seizure, characterized by a brief loss of awareness and a blank stare. Absence seizures typically do not have an aura preceding them.
Correct Answer is C
Explanation
A. Increased blinking
Increased blinking is not a typical manifestation of bradykinesia. In fact, individuals with Parkinson's disease may experience reduced blinking (hypokinesia of blinking) rather than increased blinking.
B. States of euphoria
Euphoria is not typically associated with bradykinesia. Instead, individuals with Parkinson's disease may experience a range of mood changes, including depression, anxiety, or apathy, but euphoria is not a common finding.
C. Slurred speech
This is the correct answer. Slurred speech, or dysarthria, can occur in individuals with Parkinson's disease as a result of bradykinesia affecting the muscles involved in speech production. Bradykinesia can cause a reduction in the speed and coordination of movements necessary for clear speech, resulting in slurred or mumbled speech patterns.
D. Decreased respiratory rate
Decreased respiratory rate is not typically associated with bradykinesia. Bradykinesia primarily affects voluntary movements rather than involuntary processes such as respiration. While respiratory muscle weakness can occur in advanced stages of Parkinson's disease, it is not directly related to bradykinesia.
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