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. "We will wrap our baby in a blanket under the car seat straps when it is cold out.": Placing a blanket under the straps can prevent proper restraint and reduce the effectiveness of the harness, increasing the risk of injury during a crash. Blankets should go over the secured straps instead.

B. "We will make sure to activate the air bag when we place the car seat in the front passenger seat.": Airbags can cause serious injury or death to infants in the event of a collision. Infants should always ride in the back seat, away from active airbags.

C. "We will switch our baby's car seat to forward facing when they turn one.": Current safety guidelines recommend keeping infants in a rear-facing car seat until at least 2 years of age or until they reach the maximum height and weight allowed by the car seat manufacturer.

D. "We will check the temperature of the car seat surface before placing our baby in the seat when it is hot out.": Checking the car seat’s surface temperature helps prevent burns from hot straps or seat material. This demonstrates understanding of infant safety measures during car seat use.

A. To stay with the client's body for 8 hr following their death B. To bury the client's body within 24 hr of the death C. To cremate the client's body D. To prohibit medical personnel from touching the client's body

Correct Answer is C

Explanation

A. To stay with the client's body for 8 hr following their death: While family presence is important, there is no specific Hindu requirement for remaining with the body for a set number of hours. Practices vary, and extended vigil is not a universal expectation.

B. To bury the client's body within 24 hr of the death: Hindu tradition typically favors cremation rather than burial. Burial within a specific timeframe is not commonly observed in Hindu customs.

C. To cremate the client's body: Cremation is the preferred method of body disposition in Hinduism, as it is believed to release the soul from the physical body and aid in the process of reincarnation. Nurses should anticipate and facilitate cremation requests according to religious customs.

D. To prohibit medical personnel from touching the client's body: While modesty and respect are important, Hindu practices generally do not prohibit caregivers from providing postmortem care. Proper handling with reverence and adherence to rituals is expected rather than a complete prohibition.

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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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