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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. “Place a warm, wet washcloth over your child’s forehead and the bridge of their nose.": Warm compresses can dilate blood vessels and potentially worsen the bleeding. A cold compress or direct pressure is more appropriate for stopping a nosebleed.
B. “Tell your child to blow their nose gently and then sit down and tilt their head backward.": Blowing the nose can dislodge clots and increase bleeding, and tilting the head backward risks aspiration of blood. The head should be tilted slightly forward.
C. “Use your thumb and forefinger to apply pressure to the sides of your child's nose.": Applying continuous pressure to the soft part of the nose for about 10 minutes helps compress blood vessels and promotes clot formation, which is the correct first-aid response for a nosebleed.
D. "Have your child lie down and turn their head to the side for 10 minutes.": Lying down can increase blood flow to the head and promote continued bleeding. Additionally, turning the head to the side risks aspiration of blood into the airway.

A. Mucus membranes B. Integumentary findings C. Emesis D. Behavior E. AST result F. Vital signs G. Movement of hands and fingers

Correct Answer is ["B","D","F"]

Explanation

A. Mucous membranes: Although they are noted to be dry, this alone is not an urgent finding. Mild dehydration may be monitored, especially when the client is stable and has IV access established.
B. Integumentary findings: Scratch marks and intense pruritus are consistent with cholestasis from liver dysfunction. This can lead to excoriation, infection, or indicate worsening hepatic failure, especially in the context of jaundice and elevated bilirubin.
C. Emesis: No vomiting or emesis is mentioned anywhere in the case details, making this an irrelevant and unsupported option for follow-up.
D. Behavior: The client is disoriented to time and displaying agitation with inappropriate language. In a client with alcohol use disorder and cirrhosis, this behavior can indicate the onset of hepatic encephalopathy which can rapidly progress and require immediate attention.
E. AST result: The AST level is significantly elevated (208 units/L), but liver enzymes are not immediate threats requiring urgent action. They confirm liver injury but do not direct acute intervention.
F. Vital signs: The client has a significantly elevated blood pressure (188/94 mmHg), tachycardia (120/min), and an increased temperature (38.4°C). These may reflect an acute withdrawal syndrome, sepsis, or intracranial injury—all of which demand urgent follow-up.
G. Movement of hands and fingers: There is no indication of tremors, asterixis, or motor deficits in the notes. Therefore, hand and finger movement does not currently present as a priority concern.

View Question and Answer

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

A nurse is caring for a client who has just started having a seizure. Which of the following interventions should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse receives a telephone call from a parent reporting that their school-age child has a nosebleed and that they cannot stop the bleeding. Which of the following instructions should the nurse provide to the parent?

Correct Answer is C

Explanation

Exhibits Select the 3 findings that require immediate follow-up by the nurse.

Correct Answer is ["B","D","F"]

Explanation

A nurse is teaching a new parent about breastfeeding her 2-week-old infant. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is assessing a client who has obsessive-compulsive personality disorder. Which of the following manifestations should the nurse expect?

The nurse continues to care for the client. Exhibits Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is most likely experiencing dropdownas evidenced by the client'sdropdown.

A nurse in a clinic is caring for a client who is pregnant and asks how she should help her 4-year.old son prepare for the new baby. Which of the following statements should the nurse make?

A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include?

A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication. Which of the following interventions should the nurse include in the plan?

A nurse is providing teaching to a client who is to undergo a cardiac catheterization. Which of the following findings is expected during the procedure?

A nurse in a mental health facility is caring for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse take?