A nurse is assisting a client to ambulate when the client begins to have a generalized seizure, identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Turn the client's head to the side

Guide the client to the floor.

Provide supplemental oxygen

Provide hygiene.

Initiate reorientation

Answer and Explanation

The Correct Answer is B,A,C,D,E

A. Turn the client's head to the side: Turning the head to the side helps maintain airway patency and allows saliva or secretions to drain, reducing the risk of aspiration. This action is performed once the client is safely positioned and seizing. Airway protection is a priority during active seizure activity.

B. Guide the client to the floor: Safely guiding the client to the floor prevents injury from a fall during sudden loss of muscle control. This is the first priority when a seizure begins during ambulation. Protecting the client from trauma takes precedence over all other actions.

C. Provide supplemental oxygen: After the seizure activity subsides, oxygen may be needed to address hypoxia caused by impaired breathing during the seizure. Supplemental oxygen supports adequate tissue oxygenation during the postictal phase. This action follows airway positioning and stabilization.

D. Provide hygiene: Hygiene care is provided after the seizure once the client is stable, as incontinence or excessive secretions may have occurred. Maintaining cleanliness promotes comfort and dignity. This step is not urgent and is addressed after physiologic needs are met.

E. Initiate reorientation: Reorientation is performed last, during the postictal phase, when the client may be confused or disoriented. Calm reassurance and simple explanations help reduce anxiety and support neurologic recovery. This action is appropriate only once the client is alert and stable.

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Correct Answer is D

Explanation

A. Open the flap on the sterile kit nearest to the nurse and place the flap on the work surface: Opening the flap closest to the nurse first increases the risk of contaminating the sterile field. The nurse’s arms and clothing could cross over the field, compromising sterility.

B. Open the side flap of the sterile kit, allowing it to lie flat on the work surface: Side flaps are opened after the flap farthest from the nurse. Opening side flaps prematurely can increase the chance of contaminating the sterile contents.

C. Apply sterile gloves: Sterile gloves are applied after the sterile field has been properly opened and prepared. Donning gloves before opening the sterile kit does not follow the correct sequence of steps.

D. Open the outermost flap of the sterile kit away from the nurse's body: Opening the flap farthest from the nurse first prevents reaching over the sterile field. This action helps maintain sterility and establishes a safe sterile field for the procedure.

A. Limit the number of choices for the client. B. Provide a stimulating environment for the client. C. Use written signs to assist the client with locating the bathroom. D. Use confrontation to manage the client's behavior

Correct Answer is A

Explanation

A. Limit the number of choices for the client: Offering too many options can overwhelm a client with Alzheimer’s disease and increase confusion or agitation. Limiting choices helps the client make decisions more easily and promotes a sense of control.

B. Provide a stimulating environment for the client: Excessive stimulation can increase confusion, agitation, and anxiety in clients with Alzheimer’s disease. A calm, structured environment is more appropriate to support cognitive function and reduce behavioral disturbances.

C. Use written signs to assist the client with locating the bathroom: As Alzheimer’s progresses, clients often lose the ability to read or interpret written language (alexia). Using pictures or symbols (e.g., a picture of a toilet on the bathroom door) is much more effective than written words for assisting with navigation.

D. Use confrontation to manage the client's behavior: Confrontation can escalate agitation and aggression in clients with Alzheimer’s disease. Approaches should focus on redirection, reassurance, and validation rather than confrontation.

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A nurse is assisting a client to ambulate when the client begins to have a generalized seizure, identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

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