A nurse finds a client on the floor of their room experiencing a seizure. Which of the following actions is the nurse's priority?

Place the client on their side with their head forward.

Administer an anticonvulsant medication.

Time the length of the client's seizure.

Loosen the client's gown and allow them to move freely.

Answer and Explanation

The Correct Answer is A

A. Place the client on their side with their head forward. This position helps maintain an open airway, prevents aspiration, and allows secretions to drain. It is the priority intervention during an active seizure.

B. Administer an anticonvulsant medication. Medications like benzodiazepines (e.g., lorazepam) are used to stop prolonged seizures but are not the immediate priority over airway protection.

C. Time the length of the client's seizure. While monitoring seizure duration is important, ensuring airway protection and safety comes first.

D. Loosen the client's gown and allow them to move freely. While restrictive clothing should be loosened, allowing unrestricted movement could lead to self-injury.

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Correct Answer is B

Explanation

A. Ask the client to tilt their head back when swallowing. Tilting the head back increases the risk of aspiration by opening the airway. Instead, the "chin tuck" method is recommended.

B. Have the client sit upright for 1 hr following meals. Sitting upright for an extended period reduces the risk of aspiration by allowing gravity to assist in digestion.

C. Administer liquids to the client using a syringe. Using a syringe can increase the risk of aspiration and does not allow the client to control swallowing.

D. Allow the client to rest for 10 min prior to eating. While rest may help conserve energy, it is not a priority intervention for dysphagia management.

A. "Contacted the provider to report client findings." B. "Reports stomach pain as 3 on a pain scale of 0 to 10." C. "Vomited 120 mL of clear, yellow emesis." D. "Denies further nausea or vomiting since antiemetic administration.

Correct Answer is D

Explanation

A. "Contacted the provider to report client findings." – This is an example of collaboration or communication, not direct implementation of care.

B. "Reports stomach pain as 3 on a pain scale of 0 to 10." – This is assessment, not implementation.

C. "Vomited 120 mL of clear, yellow emesis." – This is also assessment (objective data collection).

D. "Denies further nausea or vomiting since antiemetic administration." – This is implementation, as it evaluates the effect of an intervention (antiemetic administration).

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A nurse finds a client on the floor of their room experiencing a seizure. Which of the following actions is the nurse's priority?

Nursing Test Bank

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