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 {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

Incorrect Options

Osteoporosis: This condition is primarily characterized by bone density loss and an increased risk of fractures. It would not be indicated by bilateral wrist and shoulder stiffness. Instead, osteoporosis symptoms include bone density loss and potentially fractures.
Hypertension: Hypertension involves consistently high blood pressure. Bilateral wrist and shoulder stiffness are not typical symptoms of hypertension. The primary indicator for hypertension is elevated blood pressure.
Diabetes Mellitus: This metabolic disorder is characterized by high blood glucose levels. Symptoms related to diabetes include elevated blood glucose levels, not joint stiffness.
Chronic Obstructive Pulmonary Disease (COPD): COPD is a respiratory condition marked by shortness of breath, chronic cough, and other respiratory symptoms. It would not be indicated by joint stiffness but rather by respiratory difficulties such as shortness of breath.

In contrast, rheumatoid arthritis is an autoimmune disease that primarily affects the joints, leading to symptoms such as bilateral wrist and shoulder stiffness. Therefore, the correct answer is "rheumatoid arthritis" and "bilateral wrist and shoulder stiffness," while the incorrect options provided do not align with the symptoms of rheumatoid arthritis.

A. "Do you have a plan for harming yourself?" B. "Do you have someone to discuss your feelings with?" C. "Has anyone in your family ever died by suicide?" D. "Can you tell me about the stresses in your life?"

Correct Answer is A

Explanation

A. Correct. Assessing whether the client has a plan for self-harm is a priority in evaluating the immediate risk of suicide. If a plan is present, further assessment and intervention are needed.
B. Incorrect. While having support is important, knowing whether the client has a plan for self-harm takes precedence.
C. Incorrect. While a family history of suicide is a risk factor, it is not as immediate a concern as determining whether the client has a current plan.
D. Incorrect. Assessing the sources of stress is important, but the immediate risk of self-harm takes priority.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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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?