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 A
Explanation
A. Correct. Pancre-lipase is an enzyme replacement therapy used in cystic fibrosis to improve digestion and absorption of fats. Reduction in fat in the stools indicates improved fat digestion.
B. Improved absorption of vitamins B and C might occur as a result of improved overall digestion, but it is not the primary therapeutic effect of pancre-lipase.
C. Improved respiratory function is not a direct effect of pancre-lipase.
D. Decreased sodium excretion is not a primary therapeutic effect of pancre-lipase.
Correct Answer is C
Explanation
A. Placing a pillow between the legs can actually provide support and comfort when lying on the back or non-operative side.
B. Gentle exercises are typically encouraged after hip arthroplasty to promote circulation and prevent complications.
C. Correct. Avoiding lying on the operative side helps prevent dislocation of the new hip joint.
D. Avoiding crossing the legs helps prevent hip joint stress, but avoiding lying on the operative side is more crucial.
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