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 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.

A. "It's nice having other people cook for me." B. "I've never been the kind of person to ask others for help." C. "T'm looking forward to being able to be independent again." D. "really don't know what I'm supposed to do all day."

Correct Answer is A

Explanation

A. "It's nice having other people cook for me.":

This statement suggests adaptation to the new situational role. The client expresses a positive view of receiving help and support in daily activities, indicating a level of acceptance and adjustment to the changed living situation.

B. "I've never been the kind of person to ask others for help.":

This statement suggests a reluctance to seek help, and it may indicate a struggle with the new situational role. Adaptation often involves a willingness to accept assistance and support from others when needed.

C. "I'm looking forward to being able to be independent again.":

This statement indicates a positive attitude toward regaining independence, but it may not necessarily indicate full adaptation to the new situational role. The client is expressing a future orientation, and the actual adaptation will be evident when independence is achieved.

D. "I really don't know what I'm supposed to do all day.":

This statement suggests confusion or uncertainty about the daily routine, which may indicate a lack of adjustment to the new living situation. Adaptation involves a sense of understanding and comfort with one's roles and activities.

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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?

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