A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?
Place a pillow under the client’s head.
Insert a padded tongue blade into the client’s mouth.
Apply a face mask for oxygen administration.
Gently restrain the client’s extremities.
The Correct Answer is A
Choice A reason:
Place a pillow under the client’s head: During a tonic-clonic seizure, it is crucial to protect the client’s head from injury. Placing a pillow or any soft object under the head can help prevent head trauma caused by the convulsions. Ensuring the client’s safety by protecting their head is a primary concern during a seizure.
Choice B reason:
Insert a padded tongue blade into the client’s mouth: This action is incorrect and potentially dangerous. Inserting any object into the mouth during a seizure can cause injury to the teeth, gums, or jaw. It can also obstruct the airway. The myth that a person can swallow their tongue during a seizure is false, and no object should be placed in the mouth.
Choice C reason:
Apply a face mask for oxygen administration: While providing oxygen can be beneficial after the seizure has ended, during the seizure, the priority is to ensure the client’s safety and prevent injury. Applying a face mask during the active phase of a seizure is not practical and can interfere with managing the seizure safely.
Choice D reason:
Gently restrain the client’s extremities: Restraining the client’s extremities during a seizure is not recommended. Attempting to restrain the movements can cause injury to both the client and the nurse. The focus should be on protecting the client from harm without restricting their movements.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
0730: Regular insulin, also known as short-acting insulin, typically begins to work within 30 minutes after administration. Therefore, ensuring the client receives breakfast at 0730, which is 15 minutes after the insulin dose, aligns with the onset of insulin action. This timing helps to prevent hypoglycemia by ensuring that glucose from the meal is available when the insulin starts to lower blood sugar levels.
Choice B reason:
0745: Administering breakfast at 0745, which is 30 minutes after the insulin dose, might be slightly delayed. While it is still within the effective window, it is better to have the meal a bit earlier to ensure that glucose is available as soon as the insulin begins to act.
Choice C reason:
0815: Providing breakfast at 0815, which is an hour after the insulin dose, is too late. By this time, the insulin would have already started to lower blood glucose levels significantly, increasing the risk of hypoglycemia. It is crucial to match the timing of food intake with the insulin action to maintain stable blood sugar levels.
Choice D reason:
0720: Serving breakfast at 0720, which is only 5 minutes after the insulin dose, is too early. The insulin would not have started to act yet, and the blood glucose levels might rise too high before the insulin begins to lower them. It is important to wait at least 15-30 minutes after administering regular insulin before eating.
Correct Answer is B
Explanation
Choice A reason:
Saying “Maybe next time you can have a vaginal delivery” is not supportive and may minimize the client’s current feelings of disappointment. It is important to acknowledge and validate the client’s emotions rather than focusing on future possibilities.
Choice B reason:
This response, “It sounds like you are feeling sad that things didn’t go as planned,” is empathetic and validates the client’s feelings. It shows that the nurse is listening and understands the client’s disappointment, which is crucial for emotional support.
Choice C reason:
While it is true that having a healthy baby is important, saying “At least you know you have a healthy baby” can come across as dismissive of the client’s feelings. It is essential to address the client’s emotions directly rather than shifting the focus.
Choice D reason:
Telling the client “You can resume sensations sooner than if you had delivered vaginally” is not relevant to the client’s expressed feelings of disappointment about not having a natural childbirth. This response does not address the emotional aspect of the client’s experience.
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