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 D
Explanation
Choice A reason: Airborne
Airborne precautions are used for diseases that are transmitted through tiny airborne particles that can remain suspended in the air and be inhaled by others. Examples of diseases requiring airborne precautions include tuberculosis, measles, and chickenpox. These diseases can spread over long distances and through ventilation systems. Pertussis, however, is not transmitted via airborne particles but rather through larger respiratory droplets.
Choice B reason: Contact
Contact precautions are used for infections that are spread by direct or indirect contact with the patient or the patient’s environment. This includes infections like methicillin-resistant Staphylococcus aureus (MRSA) and Clostridioides difficile (C. diff). While contact precautions are important for preventing the spread of certain infections, pertussis is primarily spread through respiratory droplets, making droplet precautions more appropriate.
Choice C reason: Protective
Protective precautions, also known as reverse isolation, are used to protect immunocompromised patients from potential infections. This type of precaution is not intended to prevent the spread of infections from the patient to others but rather to protect the patient from external sources of infection. Examples include patients undergoing chemotherapy or those with severe immunodeficiency. Pertussis does not require protective precautions as it is not about protecting the patient from others.
Choice D reason: Droplet
Droplet precautions are the appropriate transmission-based precautions for pertussis. Pertussis, also known as whooping cough, is spread through respiratory droplets that are produced when an infected person coughs, sneezes, or talks. These droplets can travel short distances and can infect others who are in close proximity. Droplet precautions include wearing a mask when within 3 feet of the patient, placing the patient in a private room if possible, and ensuring that the patient wears a mask if they need to be transported.
Correct Answer is C
Explanation
Choice A reason:
Pruritus: Pruritus, or itching, can be uncomfortable and may indicate underlying conditions such as dry skin, allergies, or liver disease. However, it is not typically an immediate threat to health and can often be managed with topical treatments or antihistamines.
Choice B reason:
Swollen gums: Swollen gums can be a sign of gingivitis or other dental issues. While important to address, it is not usually an urgent condition unless it is causing severe pain or infection. Dental problems can lead to complications if untreated, but they are generally not life-threatening.
Choice C reason:
Dysphagia: Dysphagia, or difficulty swallowing, is a serious condition that can lead to aspiration, malnutrition, and dehydration. It can be caused by neurological disorders, structural abnormalities, or other medical conditions. Because it can directly impact the client’s ability to eat and drink safely, it is a priority for immediate assessment and intervention.
Choice D reason:
Urinary hesitancy: Urinary hesitancy, or difficulty starting urination, can be a symptom of benign prostatic hyperplasia (BPH) or other urinary tract issues. While it can cause discomfort and lead to urinary retention, it is generally not as immediately life-threatening as dysphagia.
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