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 B
Explanation
"Most people are scared their first time in a health care facility":
While this statement normalizes the client's feelings by suggesting that many people feel scared initially, it might not directly address the client's specific concerns or provide the opportunity for a personalized discussion about their stay.
"We can discuss what you can expect during your stay":
This statement acknowledges the client's anxiety and opens the door for a conversation about the client's concerns. It provides an opportunity for the nurse to offer information, address specific worries, and offer support, fostering a sense of control for the client.
"You have nothing to worry about. Everything will be fine":
This statement, though well-intentioned, may come across as dismissive and overly optimistic. It might not validate the client's feelings or offer the opportunity for the client to express and discuss their concerns.
"Why are you feeling scared about being in this facility?":
While open-ended questions can help explore the client's feelings, in this context, it might be better to initially offer information and support before delving into the specific reasons for the client's anxiety. This allows the nurse to establish rapport and provide reassurance first.
Correct Answer is A
Explanation
A. Use trochanter rolls beside the client's legs:
Trochanter rolls are positioning devices placed alongside the thighs to prevent external rotation of the hips when a client is lying supine. This helps maintain proper alignment and prevents hip contractures, especially in clients who are immobile.
B. Logroll the client every 4 hr:
Logrolling is a technique used to turn a client with spinal precautions, such as after spinal surgery or injury. It involves turning the entire body as a unit to avoid twisting the spine. However, in a general plan of care for an immobile client, logrolling every 4 hours may not be necessary unless there are specific medical indications.
C. Place the client's arms at their side when turning them:
Placing the client's arms at their side may not be the most optimal positioning during turns, as it can contribute to joint contractures. The nurse should consider positioning the arms in a manner that maintains joint flexibility and prevents contractures.
D. Cross the client's ankles when lying supine:
Crossing the client's ankles when lying supine is not a recommended practice. It can lead to pressure on the lateral aspect of the knees and ankles, potentially causing discomfort and impairing circulation. It is important to maintain proper alignment and support for the client's lower extremities.
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