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 B
Explanation
The correct answer is choiceB. Fever.
Choice A rationale:
Peeling of the hands and feet is not a typical manifestation of pertussis.This symptom is more commonly associated with conditions like Kawasaki disease.
Choice B rationale:
Fever is a common symptom in the early stages of pertussis, along with a mild cough and runny nose.
Choice C rationale:
A beefy, red tongue is not associated with pertussis.This symptom is more characteristic of scarlet fever.
Choice D rationale:
Facial erythema is not a typical symptom of pertussis.Pertussis primarily affects the respiratory system, causing severe coughing fits.
Correct Answer is C
Explanation
A. Incorrect. Justice refers to fairness and equitable treatment of clients. While important, it does not specifically pertain to the nurse's communication about medication adverse effects.
B. Incorrect. Autonomy refers to the client's right to make decisions about their own care and treatment. While truthfully communicating about medication's adverse effects supports autonomy, veracity is the ethical concept specifically related to truthfulness.
C. Correct. Veracity is the ethical concept of truthfulness and honesty in communication. When the nurse communicates truthfully about the potential adverse effects of the medications, they are demonstrating veracity.
D. Incorrect. Beneficence refers to the duty to do good and promote the well-being of the client.
While important, it is not the ethical concept specifically related to truthful communication about medication's adverse effects.
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