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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. Security bands should not be removed or transferred to others. They help ensure the correct identification of both the mother and the baby.
B. Incorrect. Carrying the baby to the nursery might not be necessary, and newborns should be transported in a safe manner, often in a crib.
C. Correct. Both the mother and the baby should have matching identification bands to prevent mix-ups and ensure proper identification.
D. Incorrect. Newborns should generally remain in designated safe areas, like the mother's room or the nursery, to ensure their safety and security.
Correct Answer is A
Explanation
A. Correct. Reducing salt intake is an important dietary modification for managing hypertension.
A limit of 2 grams per day is in line with recommended guidelines.
B. Incorrect. The recommended amount of exercise for managing hypertension is at least 150 minutes of moderate-intensity aerobic activity per week, not just 15 minutes twice a week.
C. Incorrect. Alcohol consumption should be limited or moderated, and the client should be cautious about alcohol interactions with blood pressure medication.
D. Incorrect. The blood pressure goal for individuals with hypertension is often set lower, around 130 over 80 or even lower, to reduce the risk of cardiovascular complications.
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