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 C

Explanation

Choice A reason: Veracity

Veracity refers to the ethical principle of truthfulness and honesty. In the context of nursing, it involves providing accurate and complete information to patients. While veracity is crucial in maintaining trust between the nurse and the patient, it is not directly related to the decision to discontinue a medication due to adverse effects.

Choice B reason: Fidelity

Fidelity involves being faithful to commitments and promises made to patients. It includes maintaining confidentiality and being loyal to the patient’s best interests. Although fidelity is important in the nurse-patient relationship, it does not specifically address the ethical considerations involved in discontinuing a harmful medication.

Choice C reason: Nonmaleficence

Nonmaleficence is the ethical principle of doing no harm. In this scenario, discontinuing the experimental chemotherapy medication due to evidence of rapidly advancing kidney failure aligns with the principle of nonmaleficence. The nurse and healthcare team are acting to prevent further harm to the patient by stopping a treatment that is causing significant adverse effects.

Choice D reason: Autonomy

Autonomy refers to respecting the patient’s right to make their own decisions about their healthcare. This includes providing the patient with all necessary information to make informed choices. While autonomy is a fundamental ethical principle, the decision to discontinue the medication in this case is primarily based on preventing harm, which aligns more closely with nonmaleficence.

A. Draw sheet B. Log roll C. Sliding board D. Hoyer lift

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.

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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?

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Correct Answer is C

Explanation

A nurse is preparing to turn a client who is obese following a spinal fusion. The nurse should plan to use which of the following techniques to turn this client?

Correct Answer is B

Explanation

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