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. Place a trochanter roll against the thigh. B. Place a sandbag to the lateral calf. C. Place a wedge pillow between the legs. D. Place a footboard on the bed.

Correct Answer is C

Explanation

An appropriate action to prevent hip dislocation in a client who is postoperative following a total hip arthroplasty is to place a wedge pillow between the legs. This helps to maintain proper alignment and prevent the legs from crossing or adducting, which can cause hip dislocation.

Placing a trochanter roll against the thigh, placing a sandbag on the lateral calf, and placing a footboard on the bed are not appropriate actions to prevent hip dislocation in this situation. A trochanter roll is used to prevent the external rotation of the hip. A sandbag to the lateral calf can help prevent foot drop. A footboard can help prevent plantar ﬂexion contractures.

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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

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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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?