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.
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Related Questions
Correct Answer is D
Explanation
A. Ask each nurse to take turns making the assignments: This may seem fair, but it avoids addressing the underlying conflict and could lead to inconsistent or biased assignments. It doesn't promote teamwork or long-term resolution.
B. Tell the nurses that the assignments will be more equitable in the future: This is a vague promise that doesn't actively involve the nurses in resolving the conflict. It may not build trust or address the root perception of favoritism.
C. Arrange for the nurses to have as few shifts together as possible: Separating the nurses may reduce short-term tension, but it avoids the issue and fails to improve communication or working relationships between team members.
D. Encourage collaboration between the two nurses when making the assignments: This strategy promotes open communication, mutual understanding, and shared responsibility. It empowers both nurses to contribute to the process and helps build trust and teamwork.
Correct Answer is A
Explanation
A. Ask the client if they would prefer a translator who is the same gender: Cultural sensitivity includes acknowledging gender preferences in healthcare interactions. Offering a choice respects the client’s values and supports effective, respectful communication.
B. Ask a nursing student who speaks the same language as the client to translate: Using untrained staff or students as interpreters can lead to errors or breaches in confidentiality. Only qualified medical interpreters should be used to ensure accuracy and professionalism.
C. Use a website with a ".com" URL to translate for the client: Online translation tools are not reliable for medical communication. They can lead to serious misunderstandings and are not appropriate for clinical use.
D. Request a family member of the client to translate: Family members may lack the language skills or medical knowledge to translate accurately and may filter or misinterpret information. This can compromise informed consent and patient safety.
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