A nurse is assessing a client who is receiving treatment for psoriasis. Which of the following images depicts what the nurse should expect to observe?

Rationale

A. Monitor the client's respiratory and cardiac status: During a tonic-clonic seizure, the client is at risk for hypoxia, apnea, and cardiac arrhythmias. Continuous assessment of vital signs and oxygenation is critical to detect complications and provide immediate intervention if needed. Monitoring ensures the client’s safety throughout the seizure episode.

B. Place the client in a supine position during the seizure: Placing the client supine increases the risk of aspiration. The recommended position is lateral (side-lying) to maintain airway patency and allow secretions to drain, reducing the risk of choking or airway obstruction.

C. Offer the client a cup of juice to drink once the seizure is over: Giving fluids immediately after a seizure may risk aspiration if the client is still disoriented or has impaired swallowing. The nurse should first assess the client’s level of consciousness and swallowing reflex before offering oral intake.

D. Use a padded tongue blade to protect the client's tongue while seizing: Inserting any object into the mouth during a seizure can cause dental injury, airway obstruction, or trauma. Current guidelines advise against using tongue blades or other objects; protecting the head and keeping the airway clear is the safest approach.

Rationale

A. Advance the needle 6 mm (1/4 in) below the skin's surface: The needle should not be advanced below the dermis because intradermal injections require placement within the superficial skin layers. Advancing too deeply can result in subcutaneous injection, which may produce a false-negative result.

B. Insert the needle at a 20° angle to the client's skin: Intradermal injections should be administered at a very shallow angle, typically 5–15°, to ensure proper placement just under the epidermis. A 20° angle risks injecting too deeply and compromising test accuracy.

C. Point the bevel of the needle upward prior to insertion: Keeping the bevel upward allows for smooth entry into the dermis and helps form a visible wheal, which is necessary to confirm correct intradermal placement. This technique minimizes tissue trauma and ensures the test can be accurately read.

D. Administer the injection on the dorsal forearm: The recommended site for a tuberculin skin test is the inner surface of the forearm, not the dorsal side. The inner forearm provides a flat, easily accessible area that allows for accurate observation and measurement of induration.