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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Elevate full-length side rails on both sides of the client's bed:

While side rails are used to prevent falls, full-length side rails can pose a risk to the client. They may give a false sense of security, and there's a risk of entrapment or injury if the client tries to climb over them. The use of side rails requires careful assessment and consideration of the individual client's needs.

B. Place the bedside table 0.9 m (3 feet) away from the bed:

Placing the bedside table 0.9 m (3 feet) away from the bed may not directly address the risk of falls. The focus should be on making essential items easily accessible to the client to minimize the need for them to get out of bed, especially during the night. Placing items within the client's reach is a more practical approach.

C. Keep the client's room temperature at 18°C (64.4°F):

While maintaining a comfortable room temperature is important for the client's overall well-being, it is not a direct preventive measure for falls. Falls are more likely to be prevented by addressing environmental factors, ensuring clear pathways, and providing adequate lighting.

D. Provide the client with a night light:

This is the appropriate action. A night light helps improve visibility during nighttime, reducing the risk of falls. It allows the client to see their surroundings better and navigate the room safely if they need to get out of bed.

A. "You shouldn't worry about the future so you can concentrate on getting well." B. "if you work hard on your physical therapy, you won't need to worry." C. "You're concerned about what will happen when you leave the hospital?" D. "Why are you concerned even though everyone is here to help you?"

Correct Answer is C

Explanation

A. "You shouldn't worry about the future so you can concentrate on getting well.":

This response dismisses the client's concerns and may make them feel invalidated. It implies that their worry is not justified and may hinder open communication about their feelings.

B. "If you work hard on your physical therapy, you won't need to worry.":

While encouragement and motivation are essential, this response may come across as minimizing the client's emotional concerns. It focuses solely on the physical aspect of recovery and does not address the broader emotional and psychological aspects of the client's worry about the future.

C. "You're concerned about what will happen when you leave the hospital?":

This response reflects active listening and empathy, acknowledging the client's expressed concern and inviting further discussion. It allows the client to express their feelings and concerns about the future, fostering a therapeutic nurse-client relationship.

D. "Why are you concerned even though everyone is here to help you?":

This response might be perceived as judgmental or dismissive of the client's feelings. It could make the client feel defensive and hesitant to share their concerns. It does not encourage open communication or exploration of the client's emotions.

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