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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason:

Draw sheet: A draw sheet can be used to assist in repositioning a patient, but it is not the most effective method for turning a client who has undergone spinal fusion. The primary concern is to maintain spinal alignment, which is best achieved through the log roll technique.

Choice B reason:

Log roll: The log roll technique is the preferred method for turning patients who have had spinal surgery. This technique involves moving the patient as a single unit, keeping the spine in alignment to prevent any twisting or bending that could disrupt the surgical site. It is especially important for obese patients to ensure that the spine remains stable during movement.

Choice C reason:

Sliding board: A sliding board is typically used to assist with transfers from one surface to another, such as from a bed to a wheelchair. It is not suitable for turning a patient in bed, particularly one who has had spinal surgery.

Choice D reason:

Hoyer lift: A Hoyer lift is a mechanical device used to lift and transfer patients who are unable to move themselves. While it can be useful for transferring patients, it is not designed for turning patients in bed and does not provide the necessary support to maintain spinal alignment during a turn.

A. Take the medication with orange juice. B. Take the medication between meals. C. Take the medication on an empty stomach. D. Take the medication with milk.

Correct Answer is D

Explanation

Choice A reason: Take the Medication with Orange Juice

Taking betamethasone with orange juice is not specifically recommended. While orange juice can help with the taste of some medications, it does not have any particular benefit for betamethasone. Additionally, citrus juices can sometimes interfere with the absorption of certain medications.

Choice B reason: Take the Medication Between Meals

Taking betamethasone between meals is not advised. This medication can cause stomach upset, and taking it on an empty stomach can exacerbate this issue. It is generally recommended to take corticosteroids with food to minimize gastrointestinal discomfort.

Choice C reason: Take the Medication on an Empty Stomach

Taking betamethasone on an empty stomach is not recommended for the same reasons as above. It can lead to stomach irritation and discomfort. Taking the medication with food or milk helps to reduce these side effects.

Choice D reason: Take the Medication with Milk

Taking betamethasone with milk is the correct instruction. Milk can help to buffer the stomach lining and reduce the risk of gastrointestinal irritation, which is a common side effect of corticosteroids. This practice helps to ensure that the medication is tolerated well by the client.

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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?

Nursing Test Bank

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