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

A.

Leave the room to initiate a rapid response.

B.

Loosen any clothing around the client's neck.

C.

Place the client in a high-Fowler’s position.

D.

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.
 


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Related Questions

Correct Answer is B

Explanation

A. Naloxone: Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, such as respiratory depression. It is not effective in treating allergic reactions like urticaria caused by antibiotics.
B. Diphenhydramine: Diphenhydramine is an antihistamine used to treat allergic reactions, including urticaria. It blocks histamine release, reducing itching, redness, and swelling associated with allergic responses.
C. Hydralazine: Hydralazine is an antihypertensive medication used to treat severe high blood pressure. It has no role in managing allergic reactions and would not address the urticaria symptoms.
D. Protamine: Protamine is used to reverse the effects of heparin in cases of overdose or bleeding. It does not counteract allergic responses and is not indicated for urticaria.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Rationale for Essential Actions:

  • Monitor for elevated temperature: Epidural anesthesia can increase the risk of maternal fever due to decreased peripheral heat loss. Monitoring temperature helps detect infection or epidural-related hyperthermia early.
  • Assess for urinary retention:Epidural anesthesia can impair bladder sensation and motor control, making urinary retention common. Ongoing bladder assessments are crucial to prevent bladder distention and associated labor complications.
  • Encourage the client to turn from side to side: Repositioning promotes fetal descent and optimal uteroplacental perfusion, and helps prevent supine hypotension by avoiding vena cava compression in laboring women.

Rationale for Contraindicated Actions:

  • Assist the client with ambulation: Epidural anesthesia impairs lower extremity motor function and balance, posing a high fall risk. Bedrest is required after epidural placement unless sensation and motor function are fully restored and evaluated.
  • Inform the client to expect drowsiness: Drowsiness is not a typical or expected effect of epidural anesthesia. Sedation may indicate systemic effects or complications and should not be presented as expected.

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