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.
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Related Questions
Correct Answer is C
Explanation
Request an interpreter during the initial assessment involves requesting the assistance of a qualified sign language interpreter to facilitate communication between the nurse and the client who is deaf. This is generally considered the most appropriate and effective option for ensuring accurate and clear communication during the admission process.
A. It may not be feasible for the nurse to become fluent in sign language immediately, learning commonly used signs can help establish basic communication and demonstrate respect for the client's communication needs. However, relying solely on this option may not be sufficient for complex communication needs or during emergencies.
B. Obtaining a board that uses colored pictures as communication may not fully address the client's needs, especially if they primarily use sign language. This option might be useful as a supplementary aid but may not be the most effective method for initial communication.
D. While having a family member present can be helpful, especially if they are proficient in sign language, it may not always be feasible or reliable. Additionally, relying on family members for interpretation can compromise the client's privacy and confidentiality, as well as potentially introduce biases or misunderstandings in communication.
Correct Answer is D
Explanation
D. After treatment for primary syphilis, it is essential for the client to have follow-up blood tests to monitor their response to treatment and ensure that the infection has been adequately treated. The follow-up blood tests are typically performed at 3, 6, and 12 months after treatment to check for resolution of the infection.
A. Syphilis is caused by a bacterial infection, not a virus. Therefore, antiviral medications are not effective for treating syphilis.
B. Cryotherapy, which involves freezing off warts or abnormal tissue, is not a treatment for syphilis.
C. Monitoring for 15 minutes after receiving each medication dose is a standard precaution for certain medications, such as vaccines or allergy injections, to monitor for any immediate adverse reactions. However, it is not necessary for syphilis.
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