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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Incorrect. No sounds heard after listening for 3 to 5 minutes would be considered absent bowel sounds.
B. Correct. Hyperactive bowel sounds are louder and more frequent than normal and can indicate increased bowel motility. They can also be present in early bowel obstructions due to increased peristalsis.
C. Incorrect. Soft sounds at a rate of 1/min are within the range of normal bowel sounds.
D. Incorrect. Decreased motility would result in hypoactive bowel sounds, not hyperactive.

A. Irrigate the indwelling catheter with 500 mL of fluid. B. Assist the client with a seat bath. C. Encourage oral fluid intake. D. Administer an enema. E. Encourage prolonged dangling before ambulation.

Correct Answer is ["B","C"]

Explanation

A. Not indicated and could lead to complications.

B. The client reports abdominal cramping and a small, hard, painful bowel movement. A sit bath can help provide relief and comfort to the perineal area, which can be beneficial after experiencing bowel discomfort.
C. The client reports pain and has had a small, hard, painful bowel movement. Encouraging oral fluid intake helps prevent dehydration and can soften the stool, making it easier to pass and reducing the risk of constipation.
D. Not necessary or appropriate without further assessment.

E. Not necessary and may not provide any additional benefit in this context.

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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?

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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?