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. Insert an oral airway into the client's mouth. Inserting anything into the client’s mouth during a seizure is contraindicated due to the risk of oral injury, aspiration, or causing airway obstruction.
B. Lower the side rails of the bed when the seizure begins. Lowering the side rails is inappropriate and increases the risk of the client falling out of bed and sustaining an injury. Instead, the nurse should ensure padded side rails are in place or protect the client by cushioning their head and limbs if side rails are not padded.
C. Measure the duration of the seizure. It is critical to measure the duration of a seizure to provide accurate information to the healthcare team. The duration helps determine the severity of the seizure and the need for medical interventions, such as administering medications to stop prolonged seizures (status epilepticus).
D. Restrain the client's arms and legs to prevent injury. Restraint during a seizure is inappropriate and can cause musculoskeletal injuries. The nurse should allow the seizure to run its course while ensuring the client’s safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Tonicclonic seizures might be part of the electroconvulsive therapy procedure itself, but they would typically occur during the treatment, not 15 minutes after.
B. Paresthesias (tingling or numbness. are not a common expected finding following electroconvulsive therapy?
C. Correct. Disorientation is a common side effect after electroconvulsive therapy and usually resolves over time.
D. Sleep apnea is not an expected finding following electroconvulsive therapy.
Correct Answer is A
Explanation
A. Correct. For a client with a pre-pregnancy BMI of 30.5 (considered obese., an acceptable weight gain during pregnancy is typically around 1120 pounds (59 kg., making 16 pounds an appropriate option within this range.
B. Incorrect. A weight gain of 32 pounds would be considered excessive for a client with a pre-pregnancy BMI of 30.5.
C. Incorrect. A weight gain of 24 pounds might still fall within an acceptable range, but for a client with a pre-pregnancy BMI of 30.5, a weight gain of 16 pounds is a more appropriate option.
D. Incorrect. A weight gain of 8 pounds would likely be insufficient for a client with a pre-pregnancy BMI of 30.5.
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