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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Allowing a family member to stay with the body is a common practice in many cultures, but it is not specific to Islamic practices.
B. Positioning the head northward is not a specific requirement of Islamic postmortem care.
C. Correct. Positioning the client's head toward Mecca is an important aspect of Islamic postmortem care, as Muslims pray facing Mecca.
D. Allowing a family member to stay with the body for a specific duration is not a specific Islamic practice.
Correct Answer is D
Explanation
Budesonide is a corticosteroid inhaler used for long-term management of asthma. It helps to reduce inflammation and prevent asthma symptoms. Rinsing the mouth and gargling with water after using a corticosteroid inhaler can help reduce the risk of developing oral thrush, a fungal infection.
The other statements are incorrect and indicate a misunderstanding of the teaching: "I will take my inhaler treatment before each meal and at bedtime": Budesonide is not typically used before meals or at bedtime. It is usually taken on a regular schedule, as prescribed by the healthcare provider, to provide long-term control of asthma symptoms.
Using the inhaler before exercising is important because physical activity can trigger asthma symptoms in some individuals. By using the inhaler before exercise, the client can help prevent exercise-induced asthma symptoms. However, this depends on the degree of difficulty of the exercise.
"I should use my inhaler when I have an asthma attack": Budesonide is not a rescue inhaler for immediate relief of asthma symptoms during an asthma attack. It is a controller medication meant to be used regularly to prevent symptoms from occurring
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