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 A

Explanation

Choice A reason: Applying a motion sensor mat to the client's bed is an appropriate action to prevent wandering and alert the staff if the client tries to get out of bed.

Choice B reason: Moving the overbed table away from the bed is not an effective action to prevent wandering, as it does not restrict the client's mobility or provide any supervision.

Choice C reason: Raising all four side rails while the client is in bed is an inappropriate action that can increase the risk of injury or entrapment if the client attempts to climb over them.

Choice D reason: Leaving the television on in the client's room is not an effective action to prevent wandering, as it does not provide any stimulation or distraction for the client.

A. I can apply lotion between my toes after showering. B. I can wear open-toe shoes. C. I should wear cotton socks. D. I should round the corners of my toenails when trimming them.

Correct Answer is C

Explanation

Choice A: This is incorrect because applying lotion between the toes can create a moist environment that promotes fungal growth and infection. The client should apply lotion to the feet but avoid the areas between the toes.

Choice B: This is incorrect because wearing open-toe shoes can expose the feet to injury and infection. The client should wear well-fitting, closed-toe shoes that protect the feet and prevent pressure ulcers.

Choice C: This is correct because wearing cotton socks can help keep the feet dry and prevent fungal infections. Cotton socks also provide cushioning and reduce friction.

Choice D: This is incorrect because rounding the corners of the toenails can cause ingrown nails, which can lead to infection and ulceration. The client should trim the toenails straight across and file any sharp edges.

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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

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