A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?
Loosen the client's clothing.
Help the client lie on the floor.
Turn the client onto their side.
Move items in the room away from the client.
The Correct Answer is B
A. Loosen the client's clothing:
While ensuring a patent airway is essential, it is not the immediate priority when the client is actively seizing. The primary concern is preventing injury by helping the client lie on the floor.
B. Help the client lie on the floor:
This is the correct answer. When a client is having a seizure, the priority is to ensure their safety. Lying the client on the floor helps prevent injury during the seizure, reducing the risk of falling from a chair or bed. Placing the client in a lateral (side) position can also help maintain an open airway.
C. Turn the client onto their side:
This action is part of the process after helping the client lie on the floor. Turning the client onto their side helps prevent aspiration in case of vomiting and maintains an open airway.
D. Move items in the room away from the client:
While creating a safe environment by moving objects away is important, the immediate priority is to prevent injury to the client. Helping the client lie on the floor takes precedence to minimize the risk of injury during the seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Exercise 1 hr before bedtime:
While regular exercise is beneficial for overall health, exercising close to bedtime may actually interfere with sleep. It is better to exercise earlier in the day
B. Drink a cup of hot cocoa before bedtime:
While a warm beverage like hot cocoa may be soothing for some individuals, it contains caffeine, which can interfere with sleep. Caffeine consumption, especially close to bedtime, is generally discouraged for those experiencing insomnia.
C. Eat a light carbohydrate snack before bedtime: can help promote sleep. Carbohydrates increase the availability of tryptophan, an amino acid that contributes to the production of serotonin (a neurotransmitter associated with relaxation and sleep).However, the snack should be light and not too heavy to avoid discomfort or indigestion during sleep
.
D. Take a 30-min nap daily:
Taking a 30-minute nap daily may not be the most effective intervention for insomnia. Napping during the day can interfere with nighttime sleep, especially if it's taken too close to bedtime. Short naps earlier in the day are generally recommended if needed.
Correct Answer is B
Explanation
A. Case manager:
The nurse manager, in this context, is not functioning as a case manager. Case management typically involves coordinating and managing the overall care plan for a client over time, including coordination of resources and services.
B. Client care provider:
The nurse manager, in this scenario, is functioning as a client care provider. By observing the newly licensed nurse perform a straight catheterization, the nurse manager is directly involved in overseeing and ensuring the safety of the client care being provided.
C. Client advocate:
While advocacy for the client is a crucial role for all nurses, the specific action described (observing the procedure) is more aligned with the role of a client care provider. Advocacy involves supporting and safeguarding the client's rights and well-being, which can be done in various nursing roles.
D. Client educator:
The nurse manager is not functioning as a client educator in this specific situation. Client education involves providing information and instruction to the client to promote their understanding and participation in their care. The nurse manager's role here is more focused on direct observation and supervision of a clinical skill.
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