A nurse is caring for a client who has just started having a seizure. Which of the following interventions should the nurse implement?
Leave the room to initiate a rapid response.
Loosen any clothing around the client's neck.
Place the client in a high-Fowler’s position.
Apply a bite block in the client's mouth.
The Correct Answer is B
A. Leave the room to initiate a rapid response: Leaving the client alone during a seizure places them at high risk for injury. The nurse should remain with the client to provide immediate safety interventions and call for help without leaving the bedside.
B. Loosen any clothing around the client's neck: Loosening clothing helps maintain an open airway and reduces the risk of choking or airway obstruction during the seizure, making it a priority intervention.
C. Place the client in a high-Fowler’s position: High-Fowler’s position is inappropriate during a seizure because it increases the risk of falling or injury. The client should be placed on their side to promote drainage of secretions and reduce aspiration risk.
D. Apply a bite block in the client's mouth: A bite block should never be inserted during an active seizure due to the risk of injuring the mouth or airway. It can only be used before a seizure in specific circumstances, if prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Coarse lung sounds: These are indicative of secretions in the larger airways and may suggest fluid overload or pulmonary complications but are not specific to cardiac tamponade and are considered a later or unrelated finding in this context.
B. Decreased jugular vein distention: Accumulation of fluid in the pericardial sac compresses the heart and impairs its ability to fill typically causing increased jugular venous pressure, so a decrease would not be expected and does not indicate early tamponade.
C. Widening pulse pressure: Narrowing, not widening, of the pulse pressure is more characteristic of cardiac tamponade due to decreased stroke volume and rising intrapericardial pressure.
D. Muffled heart sounds: This is a classic early sign of cardiac tamponade caused by fluid accumulation in the pericardial sac, which dampens the sound of the heart during auscultation. This is one of the key components of Beck's triad, along with hypotension and elevated jugular venous pressure.
Correct Answer is A
Explanation
A. "Hold your breath for 10 seconds after each puff.": This allows the medication to deposit deeply into the airways, enhancing absorption and therapeutic effect. It is a key step in proper MDI technique.
B. "Inhale rapidly for 1 to 2 seconds after depressing the canister.": Inhalation should be slow and deep over 3 to 5 seconds to allow proper delivery of the medication into the lungs.
C. “Hold the mouthpiece 4 inches away from your open mouth.”: The preferred technique is to place the mouthpiece directly in the mouth with lips sealed around it unless a spacer is used.
D. "Tilt your head forward while inhaling.": The correct method is to tilt the head slightly back to open the airway and facilitate deeper inhalation of the medication.
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