A nurse is caring for a client in bed and begins experiencing a tonic-clonic seizure.
Which of the following actions should the nurse take?
Insert an oral airway into the client's mouth.
Lower the side rails of the bed when the seizure begins.
Measure the duration of the seizure.
Restrain the client's arms and legs to prevent injury.
The Correct Answer is C
A. Incorrect. Inserting an oral airway during a seizure can lead to injury and is not recommended.
B. Incorrect. Lowering the side rails might not prevent injury during a seizure and is not the priority action.
C. Correct. Measuring the duration of the seizure is important for assessing the length of the seizure and ensuring appropriate timing of interventions.
D. Incorrect. Restraining the client's arms and legs can lead to injury and is not recommended during a seizure.
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Related Questions
Correct Answer is D
Explanation
A. The decision to place a loved one in long-term care is complex and should be made based on the family's needs and situation, not dictated by the nurse.
B. Suggesting the son find other family members for help is a reasonable idea, but it does not directly address his fatigue.
C. While taking care of a loved one is important, making the son feel obligated is not supportive or helpful.
D. Correct. Respite care provides temporary relief to caregivers and can help address the son's fatigue while ensuring his mother's needs are met.
Correct Answer is C
Explanation
The correct answer is choicec. Assign the client to a negative-pressure airflow room.
Choice A rationale:
Administering aspirin to a client with varicella zoster is not recommended due to the risk of Reye’s syndrome, a serious condition that can cause swelling in the liver and brain.
Choice B rationale:
While contact precautions are important, varicella zoster also requires airborne precautions due to its highly contagious nature. This means that simply initiating contact precautions is not sufficient.
Choice C rationale:
Assigning the client to a negative-pressure airflow room is crucial because it helps contain the airborne virus and prevents it from spreading to other areas of the hospital.
Choice D rationale:
Having visitors remain at least 0.91 m (3 feet) away from the client is a good practice, but it is not sufficient on its own to prevent the spread of the virus. Airborne precautions, including a negative-pressure room, are necessary.
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