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
A. Use an 18-gauge, 1-inch needle to administer the medication.An 18-gauge needle is too large for subcutaneous heparin injections, which require a smaller, finer needle, typically 25- to 27-gauge and ⅜- to ⅝-inch in length. The smaller gauge reduces discomfort and is appropriate for subcutaneous tissue.
B. Inject 5.1 cm (2 in) away from the umbilicus.Heparin injections should be given at least 2 inches from the umbilicus to avoid areas with dense blood vessels, which decreases the risk of hematoma formation and improves medication absorption.
C. Expel air bubble before injecting medication.For prefilled heparin syringes, the small air bubble should not be expelled, as it helps ensure the full dose is administered and can reduce bruising by sealing the medication in the tissue.
D. Massage the injection site after withdrawing the needle.Massaging the site after a heparin injection is not recommended as it increases the risk of bruising and tissue irritation. Instead, gentle pressure may be applied briefly if there is bleeding at the site.
Correct Answer is B
Explanation
A. "Increase intake of vitamin B12":
Vitamin B12 is important for various bodily functions, including the health of nerves and red blood cells, but it is not directly associated with osteoporosis prevention. Calcium and vitamin D are more critical nutrients for bone health.
B. "Walk for 30 minutes three to five times each week":
Weight-bearing exercises, such as walking, are beneficial for preventing osteoporosis. Weight-bearing activities stimulate bone formation and help maintain bone density. Regular walking for 30 minutes, three to five times per week, can contribute to overall bone health and reduce the risk of osteoporosis.
C. "Perform water aerobics three times each week":
While water aerobics is a beneficial exercise for cardiovascular health and joint flexibility, it is not as effective as weight-bearing exercises for preventing osteoporosis. Weight-bearing activities put stress on bones, promoting bone density.
D. "Maintain a lean body mass":
Maintaining a healthy body weight and lean body mass is important for overall health, but it is not a direct preventive measure for osteoporosis. Weight-bearing exercises and adequate intake of calcium and vitamin D are more specific recommendations for preventing osteoporosis.
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