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.
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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Related Questions
Correct Answer is C
Explanation
Choice A reason: Discouraging reminiscing about the past is not a helpful strategy for a client who has dementia and confusion. Reminiscing can stimulate memory, enhance mood, and promote social interaction.
Choice B reason: Asking open-ended questions that encourage the client to express their feelings is not appropriate for a client who has dementia and confusion. Open-ended questions can increase frustration and anxiety for the client who may have difficulty finding words or recalling events. The nurse should use simple, direct, and closed-ended questions instead.
Choice C reason: Using holiday decorations to provide orientation to the time of the year is a beneficial action for a client who has dementia and confusion. Holiday decorations can help the client recognize familiar cues and reduce disorientation.
Choice D reason: Encouraging multiple family members to visit the client at the same time is not advisable for a client who has dementia and confusion. Multiple visitors can overwhelm and agitate the client who may have trouble recognizing faces or voices. The nurse should limit the number of visitors and ensure they are calm and supportive.
Correct Answer is A
Explanation
Choice A reason: Urinating before and after sexual intercourse can help flush out any bacteria that may have entered the urinary tract during sexual activity, and prevent them from causing an infection.
Choice B reason: Increasing milk consumption to make the urine more alkaline is not a recommended instruction, as it may increase the risk of developing kidney stones or calcium deposits in the urinary tract.
Choice C reason: Emptying the bladder at least every 4 hours is a good practice, but not sufficient to prevent urinary tract infections. The nurse should also advise the client to drink plenty of fluids, especially water, to dilute the urine and flush out bacteria.
Choice D reason: Using vaginal douche once a week is not a recommended instruction, as it may alter the normal flora of the vagina and increase the risk of infection. The nurse should advise the client to avoid using any products that may irritate the genital area, such as perfumed soaps, sprays, or powders.
Choice E reason: Drinking cranberry juice daily is not a proven method to prevent urinary tract infections, although some studies suggest that it may have some benefits. The nurse should inform the client that cranberry juice may interact with some medications, such as warfarin, and that it may also increase the acidity of the urine, which can cause discomfort or burning sensation.
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