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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,C,D
Explanation
The order of the steps for the four-point alternate gait with crutches is as follows: move the right crutch about 10 to 15 cm (4 to 6 in), move the left foot forward, move the left crutch forward, and move the right foot forward. This gait patern provides maximum stability and support for the client by keeping three points of contact on the ground at all times.
Correct Answer is D
Explanation
A nurse collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm should monitor the client for hypertension as a manifestation of increased intracranial pressure. Increased intracranial pressure can cause changes in blood pressure, including hypertension.
a. Peripheral edema is not a manifestation of increased intracranial pressure. Peripheral edema is swelling in the extremities and can be caused by a variety of conditions.
b. Diarrhea is not a manifestation of increased intracranial pressure. Diarrhea is loose or watery stools and
can be caused by a variety of conditions.
c. Decreased pedal pulses are not a manifestation of increased intracranial pressure. Decreased pedal
pulses can indicate poor circulation to the feet and can be caused by a variety of conditions.
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