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
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Explanation
A. Correct. Montelukast is typically given once daily in the evening to manage asthma symptoms.
B. Montelukast is not a replacement for inhaled steroids. The parent should not stop the medication without consulting the healthcare provider.
C. Montelukast is not used for acute wheezing; it is a maintenance medication and not for immediate relief.
D. Montelukast can start to show benefits within a few days of starting, not necessarily 2 months.
Correct Answer is A
Explanation
A. Correct. Baked chicken breast is relatively low in potassium compared to the other options.
B. Incorrect. Orange juice is high in potassium.
C. Incorrect. Sweet potatoes are high in potassium.
D. Incorrect. Cantaloupe is moderately high in potassium.
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