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","B","C"]
Explanation
The nurse should include the following information in the community health program for caregivers of clients with Alzheimer's disease:
Use written signs to assist the client with locating the bathroom: People with Alzheimer's disease often experience cognitive decline, including difficulties with memory and orientation.
Using written signs can help them navigate their environment and find essential areas like the bathroom. Clear signage with simple and easily recognizable symbols or words can be beneficial in reducing confusion and promoting independence.
Limit the number of choices for the client: Decision-making can become overwhelming for individuals with Alzheimer's disease. Providing too many options can lead to confusion, frustration, and decision paralysis. Caregivers should simplify choices and present them one at a time to reduce cognitive burden. For example, instead of asking what the person wants to eat from a variety of options, present a limited selection of two or three choices to make the decision-making process easier.
Provide a stimulating environment for the client: Engagement in meaningful activities and a stimulating environment can help maintain cognitive function and improve the quality of life for individuals with Alzheimer's disease. Caregivers should create a safe and enriching environment that includes activities tailored to the person's abilities and interests. This can involve puzzles, music, art, reminiscing, and other activities that promote mental and social engagement.
Do not use confrontation to manage the client's behavior: Confrontation can escalate agitation, anxiety, and confusion in individuals with Alzheimer's disease. It is important for caregivers to use non-confrontational approaches when managing challenging behaviors. Strategies such as redirection, validation, empathy, and gentle persuasion are more effective in de-escalating difficult situations and promoting a calm and supportive environment.
Correct Answer is B
Explanation
Informed consent is a crucial aspect of the patient's rights and autonomy in healthcare. It involves the voluntary and knowledgeable agreement of a competent individual to undergo a specific medical intervention or procedure. The provider is responsible for explaining the procedure, its potential risks and benefits, alternative options, and any potential complications to the patient. Once the patient has received this information and has had an opportunity to ask questions, they can provide their consent by signing the informed consent form.
"We can accept verbal consent unless the surgical procedure is an emergency." Verbal consent is generally not sufficient for most non-emergency surgical procedures. Informed consent typically requires a written documentation, signed by the patient or their legally authorized representative, to ensure clarity, accountability, and legal protection.
"We require informed consent for all routine treatments." Informed consent is typically required for invasive procedures, surgeries, and treatments with potential risks. Routine treatments that are considered low risk and part of standard care may not require explicit informed consent.
However, it is still important for healthcare providers to inform and involve patients in their care decisions.
"A family member must witness your signature on the informed consent form." While it is often beneficial to have a witness to the patient's informed consent, it does not necessarily have to be a family member. The witness can be any competent individual who can attest to the patient's signing of the form and their understanding of the procedure.
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