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 C

Explanation

Ciprofloxacin is a fluoroquinolone antibiotic that can make the skin more sensitive to sunlight, leading to an increased risk of sunburn. It is important for the client to be aware of this potential side effect and take appropriate precautions, such as using sunscreen, wearing protective clothing, and avoiding prolonged sun exposure while taking the medication.

"Take an antacid if the medication causes gastrointestinal upset." Ciprofloxacin should not be taken with antacids or mineral supplements containing calcium, magnesium, aluminum, or iron, as they can interfere with the absorption of the medication. If the client experiences gastrointestinal upset, they should consult their healthcare provider for appropriate management.

"Restrict your daily fluid intake while taking this medication." It is important for the client to maintain adequate hydration while taking ciprofloxacin, as it is important for the elimination of the medication from the body. Restricting fluid intake can lead to dehydration and may affect the effectiveness of the medication. The client should be encouraged to drink plenty of fluids unless otherwise instructed by their healthcare provider.

"Expect to experience diarrhea while taking this medication." While gastrointestinal side effects such as diarrhea can occur with ciprofloxacin, it is not appropriate to state that the client should expect to experience it. Diarrhea can be a sign of a serious adverse reaction, such as Clostridium difficile infection, and should be reported to the healthcare provider for further evaluation and management.

A. "Why don't you want to learn how to give yourself your medication?" B. "I'd like to hear your thoughts about giving yourself this medication." C. "Have you considered how your decision to refuse medication will affect your family?" D. "You will suffer serious health issues if you don't take your medication."

Correct Answer is B

Explanation

A. Incorrect. This may come across as confrontational and defensive.
B. Correct. This response opens communication and shows respect for the client's concerns.
C. Incorrect. This response could be perceived as manipulative and unhelpful.
D. Incorrect. This response may create fear and resistance rather than addressing the client's concerns.

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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

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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?