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 A
Explanation
A. Sensation of skin warmth: A warm sensation is common during cardiac catheterization due to the injection of contrast dye. This feeling is typically brief and harmless, and clients should be reassured that it is an expected part of the procedure.
B. Numbness and tingling of the extremities: These symptoms may indicate compromised circulation or nerve involvement and are not expected during the procedure. If they occur, they require immediate assessment and intervention.
C. Increased salivation: Increased salivation is not associated with cardiac catheterization. It could suggest a reaction to medication or another unrelated issue, but it is not a normal response during this procedure.
D. Headache: Headaches are not expected during cardiac catheterization. If a client develops a headache, it could be related to contrast dye sensitivity, blood pressure changes, or anxiety, and would require further evaluation.
Correct Answer is A
Explanation
A. Arrange for an ethics committee meeting to address the family’s concerns: When there is a conflict between advance directives and family wishes, an ethics committee can help mediate and ensure the client’s legal rights and wishes are upheld while addressing the family's concerns.
B. Support the family's decision and initiate life-sustaining measures: Following the family’s request instead of the client’s legally documented advance directives violates the client’s autonomy and can result in legal and ethical consequences.
C. Complete an incident report: An incident report is used for errors or unexpected events, not for resolving ethical conflicts involving advance directives and treatment decisions.
D. Encourage the family to contact an attorney: While the family has the right to seek legal counsel, the nurse's role is to advocate for the client's documented wishes and follow institutional procedures for resolving disputes.
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