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.
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Related Questions
Correct Answer is C
Explanation
A. The guardian wants to accompany the child from the ED to the radiology department. This is a typical parental response and does not indicate maltreatment. Parents often want to stay with their child for reassurance.
B. The guardian states the child fell off the swing in the backyard. This is a plausible explanation for an injury in a preschooler, though the consistency of the story with the injury should still be assessed.
C. The child was brought to the ED 2 days after the injury occurred. A delay in seeking medical care for a significant injury is a potential warning sign of child maltreatment and warrants further investigation.
D. The child cries loudly when their arm is moved or manipulated. Pain with movement is expected with a fracture and does not indicate maltreatment.
Correct Answer is A
Explanation
A. Reminding the AP about confidentiality is the appropriate immediate response. The nurse should provide education and reinforce HIPAA regulations to prevent future breaches.
B. Notifying the client is unnecessary and could cause undue distress. The priority is to address the behavior and prevent further violations.
C. Notifying the ethics committee is excessive for a first-time or minor violation. This step may be necessary if breaches continue despite education.
D. Filing an incident report is not required unless the breach has significant consequences. The best first step is direct education.
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