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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Indicates an increased risk of skin breakdown. This is because significant weight loss can lead to muscle wasting and reduced subcutaneous tissue, making the skin more vulnerable.

Bronchodilators, hemoglobin level and oxygen device do not relate directly to skin breakdown

A. This medication may cause my blood pressure to increase." B. "I should take an antacid with each dose of this medication." C. "I plan to take this medication for 1 week." D. "I will have my liver function tested while I am taking this medication."

Correct Answer is D

Explanation

Regular monitoring of liver function is important while taking isoniazid because the medication can cause liver damage in some individuals.
A. Isoniazid (INH) does not typically affect blood pressure.
B. Antacids can interfere with the absorption of isoniazid, so they should be avoided or taken at least one hour before or two hours after taking isoniazid.
C. Treatment for tuberculosis typically involves taking isoniazid for a minimum of 6 to 9 months, sometimes longer, depending on the severity of the infection

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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?

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