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. The client should maintain systolic BP between 120 and 129 mm Hg.

This is an appropriate recommendation. The American Heart Association (AHA) guidelines recommend maintaining systolic BP below 130 mm Hg to reduce the risk of stroke and other cardiovascular events in individuals with a history of stroke or TIA.

B. The client should maintain systolic BP between 130 and 135 mm Hg.

This is slightly above the recommended range. While systolic BP below 135 mm Hg is generally recommended for individuals with a history of stroke or TIA, a range of 130-135 mm Hg may still be acceptable based on individual patient factors and risk assessments.

C. The client should maintain systolic BP between 136 and 140 mm Hg.

This is above the recommended range. Systolic BP between 136 and 140 mm Hg may be considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.

D. The client should maintain systolic BP between 141 and 145 mm Hg.

This is above the recommended range. Systolic BP above 140 mm Hg is generally considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.

A. Computerized tomography angiography (CTA) B. Complete blood count (CBC) C. Prothrombin time (PT) D. Transesophageal echocardiogram (TEE)

Correct Answer is A

Explanation

A.Computerized tomography angiography (CTA)

This is a likely diagnostic test that the provider may prescribe. CTA uses computed tomography (CT) imaging to visualize the blood vessels in the brain and neck. It can help identify areas of stenosis, occlusion, or other abnormalities in the blood vessels that may contribute to the TIA symptoms.

B. Complete blood count (CBC)

A complete blood count (CBC) is a routine laboratory test that assesses various components of blood, such as red blood cells, white blood cells, and platelets. While it may not be specific to diagnosing a transient ischemic attack (TIA), it can help evaluate for underlying conditions such as anemia or thrombocytosis that could contribute to TIA symptoms or increase the risk of stroke.

C. Prothrombin time (PT)

Prothrombin time (PT) is a laboratory test that evaluates the clotting ability of blood and is typically used to monitor anticoagulant therapy. While abnormal coagulation parameters may be associated with certain conditions that predispose to TIA (such as atrial fibrillation), PT alone is not a specific diagnostic test for TIA.

D. Transesophageal echocardiogram (TEE)

This is another possible diagnostic test that the provider may prescribe. TEE is a specialized echocardiogram that provides detailed images of the heart structures by inserting an ultrasound probe

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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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