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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Related Questions
Correct Answer is B
Explanation
Choice A reason: Smallpox
Smallpox is a viral disease caused by the variola virus. It was eradicated globally in 1980 through a successful vaccination campaign. Treatment for smallpox primarily involves supportive care and antiviral medications, such as tecovirimat, rather than antibiotics like ciprofloxacin. Ciprofloxacin is ineffective against viral infections, including smallpox.
Choice B reason: Anthrax
Anthrax is a serious infectious disease caused by the bacterium Bacillus anthracis. Ciprofloxacin is one of the primary antibiotics used for the treatment and post-exposure prophylaxis of anthrax. It works by inhibiting bacterial DNA gyrase, which is essential for bacterial replication. Ciprofloxacin is effective against both cutaneous and inhalational forms of anthrax, making it a critical component in the management of anthrax exposure.
Choice C reason: Ebola virus
Ebola virus disease (EVD) is caused by the Ebola virus, a member of the Filoviridae family. Treatment for EVD primarily involves supportive care, including rehydration and management of symptoms. Antiviral medications, such as remdesivir, may also be used. Ciprofloxacin, being an antibiotic, is not effective against viral infections like Ebola.
Choice D reason: Sarin gas
Sarin gas is a highly toxic nerve agent used in chemical warfare. Exposure to sarin gas requires immediate medical intervention, including the administration of antidotes such as atropine and pralidoxime, as well as supportive care. Antibiotics like ciprofloxacin are not used in the treatment of chemical agent exposure, as they do not counteract the effects of nerve agents.
Correct Answer is A
Explanation
Choice A reason: Administer the Medications 5 Minutes Apart
Administering the medications 5 minutes apart is crucial when using multiple eye drops. This practice ensures that each medication has enough time to be absorbed without being washed out by the subsequent drop. This is particularly important for medications like timolol and pilocarpine, which are used to manage intraocular pressure in glaucoma.
Choice B reason: Hold Pressure on the Conjunctival Sac for 2 Minutes Following Application of Drops
Holding pressure on the conjunctival sac (punctal occlusion) for 2 minutes after applying eye drops can help reduce systemic absorption and increase the local effect of the medication. However, this instruction is not as critical as the timing between administering different eye drops.
Choice C reason: It Is Not Necessary to Remove Contact Lenses Before Administering Medications
This statement is incorrect. Contact lenses should be removed before administering eye drops to prevent contamination and ensure proper absorption of the medication. The lenses can be reinserted after a sufficient amount of time has passed, usually around 15 minutes.
Choice D reason: Administer the Medications by Touching the Tip of the Dropper to the Sclera of the Eye
This statement is incorrect. The tip of the dropper should never touch the eye or any other surface to avoid contamination. The correct method is to hold the dropper above the eye and squeeze out the prescribed number of drops into the conjunctival sac.
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