A nurse is caring for a client who is experiencing a generalized tonic-clonic seizure. Which of the following actions should the nurse take?

Apply restraints to the client.

Administer an IV bolus of lorazepam.

Place the client in the prone position.

Insert a tongue blade into the client's mouth.

Answer and Explanation

The Correct Answer is B

Choice A reason: Applying restraints to the client is not an appropriate action, as it can cause injury or suffocation to the client during a seizure. The nurse should protect the client from harm by removing any nearby objects and padding the side rails.

Choice B reason: Administering an IV bolus of lorazepam is an appropriate action, as lorazepam is an anticonvulsant drug that can stop or shorten the duration of a seizure by enhancing the inhibitory effects of gamma-aminobutyric acid (GABA) in the brain.

Choice C reason: Placing the client in the prone position is not an appropriate action, as it can obstruct the airway and cause respiratory distress or aspiration during a seizure. The nurse should place the client in the side-lying position to facilitate drainage of oral secretions and prevent tongue biting.

Choice D reason: Inserting a tongue blade into the client's mouth is not an appropriate action, as it can cause oral trauma or choking during a seizure. The nurse should never force anything into the client's mouth during a seizure and should allow them to breathe spontaneously.

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Correct Answer is B

Explanation

Choice A reason: Passing of flatus is not a reliable indicator of colostomy function, as it can occur even when there is an obstruction or ischemia in the bowel.

Choice B reason: Stoma is pinkish-red is a sign of a healthy and well-perfused colostomy, as it indicates that the blood supply to the bowel segment is adequate and there is no necrosis or infection.

Choice C reason: Tolerating a clear liquid diet is not a specific indicator of colostomy function, as it does not reflect the amount or consistency of the stool output.

Choice D reason: Absent bowel sounds are not a normal finding for a colostomy, as they can indicate a paralytic ileus or a bowel obstruction, which can cause complications such as distension, pain, or perforation.

A. Recent onset of confusion B. Cool, clammy skin C. Decrease in pulse rate D. Increase in blood pressure

Correct Answer is A

Explanation

Choice A: This is correct. Dehydration can cause electrolyte imbalance and affect the brain function, leading to confusion, dizziness, or lethargy.

Choice B: This is incorrect. Cool, clammy skin is a sign of shock, not dehydration. Dehydration can cause dry, warm skin.

Choice C: This is incorrect. Decrease in pulse rate is a sign of bradycardia, not dehydration. Dehydration can cause increase in pulse rate as the body tries to compensate for the low blood volume.

Choice D: This is incorrect. Increase in blood pressure is a sign of hypertension, not dehydration. Dehydration can cause decrease in blood pressure as the blood volume drops.

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A nurse is caring for a client who is experiencing a generalized tonic-clonic seizure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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