A nurse is caring for a client following a seizure. Which of the following actions should the nurse take?
Apply restraints if the client is agitated.
Ambulate the client.
Position the client on their side.
Raise all of the side rails on the client's bed.
The Correct Answer is C
A. Apply restraints if the client is agitated. Restraints are not necessary and may increase distress. Post-seizure agitation should be managed with reassurance and monitoring.
B. Ambulate the client. This is unsafe because the client may be disoriented or weak, increasing the risk of falls. Rest and recovery should be prioritized.
C. Position the client on their side. This helps maintain an open airway, prevents aspiration, and facilitates secretion drainage, making it the priority intervention.
D. Raise all of the side rails on the client's bed. Raising all four side rails is considered a restraint. A safer environment should be maintained without unnecessary restriction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pulmonary tuberculosis. This is correct because tuberculosis is a highly contagious airborne disease that must be reported to the health department for tracking, treatment, and public health intervention.
B. Fibromyalgia syndrome. This is incorrect because fibromyalgia is a chronic pain condition that is not infectious and does not require mandatory reporting.
C. Herpes simplex virus. This is incorrect because herpes simplex, though contagious, is not a reportable disease.
D. Methicillin-resistant Staphylococcus aureus. This is incorrect because MRSA infections are not universally required to be reported, though some states may have specific regulations for outbreaks in healthcare settings.
Correct Answer is C
Explanation
A. A bologna sandwich on rye bread. This is incorrect because rye bread contains gluten, which must be avoided in a celiac disease diet.
B. Whole wheat pasta with shrimp. This is incorrect because whole wheat pasta contains gluten, making it unsuitable for a child with celiac disease.
C. A corn tortilla with black beans. This is correct because corn tortillas are naturally gluten-free, and black beans provide a nutritious, safe option for a child with celiac disease.
D. Low sodium vegetable soup with barley. This is incorrect because barley contains gluten, making it inappropriate for a celiac-friendly diet.
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