A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take first?
Turn the client on their side.
Perform a neurologic check.
Obtain the client's vital signs.
Notify the rapid response team.
The Correct Answer is A
A. Turning the client on their side helps prevent aspiration (inhaling fluid or vomit into the lungs) and promotes drainage of oral secretions, reducing the risk of airway obstruction during the seizure.
B. While assessing neurological status is important, it should be done after ensuring the client's safety during the seizure. This can be done after the seizure has stopped.
C. While obtaining vital signs is important for assessing the client's overall condition, it is not the immediate priority during an active seizure. Vital signs can be assessed once the seizure has stopped and the client's safety has been ensured.
D. Notifying the rapid response team may be necessary if the seizure persists beyond a certain duration (status epilepticus) or if there are complications. However, the first action should be to ensure the client's immediate safety by turning them onto their side to prevent aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Naloxone is a medication used as an opioid antagonist to reverse the effects of opioid overdose, including respiratory depression and hypotension. In this scenario, the client's symptoms suggest opioid-induced respiratory depression, making naloxone the appropriate choice to reverse the effects of morphine.
B. Protamine sulfate is used to reverse the anticoagulant effects of heparin, not for treating opioid-induced respiratory depression and hypotension.
C. Acetylcysteine is used as an antidote for acetaminophen (paracetamol) overdose, not for treating opioid-induced respiratory depression and hypotension.
D. Flumazenil is a medication used as a benzodiazepine antagonist to reverse the effects of benzodiazepine overdose or sedation.
Correct Answer is D
Explanation
D. Hot flashes are a common symptom following a bilateral orchiectomy due to the sudden decrease in testosterone levels. Hot flashes are characterized by sudden feelings of warmth, flushing, and sweating, often accompanied by a rapid heartbeat. These symptoms can be bothersome but are typically temporary and can be managed with lifestyle modifications and medications if necessary.
A. Hypoglycemia is not typically associated with a bilateral orchiectomy.
B. Testosterone, primarily produced by the testicles, plays a significant role in promoting muscle mass and strength. Removal of the testicles results in a significant decrease in testosterone production, which may lead to a gradual decline in muscle mass and strength over time.
C. Testosterone is a key hormone involved in regulating libido in both men and women. Removal of the testicles leads to a significant decrease in testosterone levels, which may result in a decrease in libido rather than an increase.
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