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.

Keep the client in a supine position.

Gently restrain the client's extremities.

Place a pillow under the client's head.

Answer and Explanation

The Correct Answer is D

The nurse should place a pillow under the client's head if the client is on the ﬂoor in the clonic phase of a tonic-clonic seizure. This can help protect the client's head from injury during the seizure.

Inserting a padded tongue blade into the client's mouth, keeping the client in a supine position, and gently restraining the client's extremities are not appropriate interventions for the nurse to take in this situation. Inserting a padded tongue blade into the client's mouth can cause injury to the teeth and gums. Keeping the client in a supine position can increase the risk of aspiration. Gently restraining the client's extremities can cause injury and is not recommended during a seizure.

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Correct Answer is A

Explanation

a.Skeletal traction is often better than skin traction for reducing and maintaining alignment of a fracture because it involves the insertion of pins, wires, or screws directly into the bone, allowing for greater force and stability.

b.Clients in skin traction typically have less mobility compared to those in skeletal traction. Skin traction is usually used for short-term purposes or less severe fractures and involves attaching weights to the skin using adhesive materials or bandages, which can limit movement to some extent.

c.Skeletal traction involves inserting hardware into the bone, which creates an entry point for potential infection. Therefore, it has a higher risk for infection compared to skin traction, which does not involve invasive procedures.

d.While both types of traction can cause discomfort, skeletal traction is typically more invasive and can be associated with more discomfort and pain due to the pins or wires inserted into the bone. Skin traction, while uncomfortable due to the adhesive and pressure on the skin, generally causes less discomfort than skeletal traction.

A. Apply the elastic compression dressing tight enough so the toes and ankle become numb. B. Place moderate weight on the aﬀected leg when walking. C. Elevate the aﬀected ankle to the level of the heart. D. Apply heat during the first 24 hr.

Correct Answer is C

Explanation

The nurse should instruct the client to elevate the aﬀected ankle to the level of the heart. Elevation helps to reduce swelling and pain by promoting venous return and decreasing blood ﬂow to the injured area. This is an important part of the RICE (Rest, Ice, Compression, Elevation) method for treating sprains and strains.

a. The elastic compression dressing should not be applied so tight that it causes numbness in the toes and ankle.
b. The client should avoid placing weight on the aﬀected leg when walking until advised by a healthcare provider.
d. Heat should not be applied during the first 24 hours after a sprain as it can increase swelling and inﬂammation.

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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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Naxlex Comprehensive Predictor Exams

A nurse is discussing skeletal and skin traction with a newly licensed nurse. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands these therapies?

Correct Answer is A

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Correct Answer is C

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