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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: This is incorrect because positioning the bedside table close to the client can help them reach their personal items and reduce the need to get out of bed.
Choice B: This is incorrect because keeping the client's bed in the low position can prevent injuries in case of a fall and make it easier for the client to get in and out of bed.
Choice C: This is incorrect because attaching the call light to the side rail of the client's bed can ensure that the client can access it easily and call for assistance when needed.
Choice D: This is correct because instructing the client to wear their own socks to the bathroom can increase the risk of slipping and falling. The client should wear non-skid footwear or slippers when walking.
Correct Answer is ["A","C","D"]
Explanation
a) You should shower instead of taking a tub bath. This is correct because showering reduces the risk of infection and promotes wound healing.
b) You may take aspirin for mild pain. This is incorrect because aspirin can increase the risk of bleeding and interfere with clotting. The client should take acetaminophen or another nonsteroidal anti-inflammatory drug (NSAID) for pain relief.
c) You should avoid lifting objects that weigh more than 8 pounds. This is correct because lifting heavy objects can strain the surgical site and cause bleeding or herniation.
d) You might see blood in your urine after coughing. This is correct because coughing can increase the pressure in the bladder and cause blood to leak from the urethra. This is normal and should subside within a few days.
e) You may resume sexual intercourse after 2 weeks. This is incorrect because sexual intercourse can cause trauma to the prostate and urethra and delay healing. The client should wait at least 6 weeks before resuming sexual activity.
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