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 B
Explanation
A. A 25-gauge needle: This needle is too small and inappropriate for accessing a venous access port. It also risks damaging the port septum and does not allow for adequate flow during infusions.
B. A noncoring needle: A noncoring (Huber) needle is specifically designed for accessing implanted ports. Its design prevents damage to the port’s septum and allows for repeated, safe access without compromising integrity.
C. A butterfly needle: Butterfly needles are intended for short-term peripheral venous access and are not designed for port access. Using one could damage the port or increase infection risk.
D. An angiocatheter: Angiocatheters are used for peripheral IV access, not for implanted ports. They do not have the correct tip design to safely access the septum of a port without causing damage.
Correct Answer is A
Explanation
A. “It sounds like you're saying that you feel uncomfortable around others.": This therapeutic response reflects the client's feelings and encourages further expression, showing empathy without judgment or assumption.
B. “How long have you struggled with your weight?": This question shifts the focus to the client’s weight history rather than their current emotional distress, which may feel dismissive or overly clinical.
C. “Have you always felt uncomfortable being overweight?": This response makes assumptions about the client's feelings and can come across as insensitive, which may inhibit open communication.
D. “Let's discuss some weight loss strategies that might work for you.”: Offering solutions too early may invalidate the client’s emotions and shift the focus away from addressing their immediate feelings of embarrassment and discomfort.
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