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 D
Explanation
A) Incorrect. The knee joint is a hinge joint that allows primarily flexion and extension.
B) Incorrect. The interphalangeal joints are hinge joints that allow primarily flexion and extension of the fingers and toes.
C) Incorrect. The ankle joint is a hinge joint that allows primarily dorsiflexion and plantarflexion of the foot.
D) Correct. The shoulder joint is a classic example of a ball and socket joint, allowing for a wide range of motion in various directions, including flexion, extension, abduction, adduction, rotation, and circumduction.
Correct Answer is D
Explanation
A. Incorrect. Cimetidine is not known to interact significantly with enoxaparin.
B. Incorrect. Docusate is a stool softener and does not typically interact with enoxaparin.
C. Incorrect. While calcium supplements may interact with certain medications, there's no significant interaction between calcium supplements and enoxaparin.
D. Correct. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID. and can increase the risk of bleeding when taken with anticoagulants like enoxaparin. Therefore, it's considered unsafe to use both together.
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