A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?
Provide oxygen.
Turn the client onto his side.
Provide privacy.
Lower the client to the floor.
The Correct Answer is D
Choice A reason: This is an important action, but not the first one. The nurse should provide oxygen after lowering the client to the floor and protecting the head, to improve the oxygenation and prevent hypoxia.
Choice B reason: This is an important action, but not the first one. The nurse should turn the client onto his side after lowering the client to the floor and protecting the head, to prevent aspiration and maintain a patent airway.
Choice C reason: This is a helpful action, but not the first one. The nurse should provide privacy after lowering the client to the floor and protecting the head, to respect the client's dignity and reduce the stimulation.
Choice D reason: This is the first action, because lowering the client to the floor and protecting the head can prevent injury and trauma to the client during the seizure. The nurse should use a pillow, blanket, or towel to cushion the head, and move any furniture or objects away from the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: Unilateral weakness is an incorrect finding, because it is more indicative of a stroke or a brain tumor than encephalitis. Encephalitis is an inflammation of the brain that can cause neurological symptoms, but they are usually bilateral and symmetrical.
Choice B reason: Stiff neck is a correct finding, because it is a sign of meningeal irritation, which can occur in encephalitis due to the involvement of the meninges (the membranes that cover the brain and spinal cord).
Choice C reason: Photophobia is a correct finding, because it is another sign of meningeal irritation, which can cause sensitivity to light and sound.
Choice D reason: Epigastric pain is an incorrect finding, because it is not related to encephalitis. Epigastric pain is more likely to be caused by a gastrointestinal disorder, such as gastritis or peptic ulcer.
Choice E reason: Lethargy is a correct finding, because it is a sign of altered mental status, which can occur in encephalitis due to the damage to the brain tissue.
Correct Answer is B
Explanation
Choice A reason: Maintaining the client's head of the bed at 20% is an incorrect action, because the head of the bed should be elevated at least 30% to prevent aspiration of the feeding.
Choice B reason: Monitoring the client’s blood glucose level is a correct action, because enteral feedings can affect the blood glucose level and the client may need insulin adjustments.
Choice C reason: Flushing the enteral feeding tube with 10 mL of cool water after each medication is an incorrect action, because cool water can cause cramping and nausea. The nurse should use warm water to flush the tube and use at least 30 mL of water to prevent clogging.
Choice D reason: Obtaining an x-ray after beginning the feeding is an incorrect action, because an x-ray should be obtained before starting the feeding to confirm the placement of the tube.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.