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

Insert an oral airway into the client’s mouth

Measure the duration of the seizure.

Lower the side rails of the bed when the seizure begins.

Restrain the client's arms and legs to prevent injury.

None

Answer and Explanation

The Correct Answer is B

A. Attempting to force an object into the oral cavity during muscle contraction causes dental trauma or jaw fractures. It significantly increases the risk of aspiration if the object breaks or triggers a gag reflex. Modern clinical guidelines strictly prohibit the insertion of any device into the mouth during active convulsions. Airway patency is maintained by placing the client in a lateral position.

B. Tracking the exact duration of the ictal phase is a critical nursing responsibility for clinical assessment. This data determines the necessity for emergency benzodiazepines if the event lasts longer than 5 minutes. Precise timing helps differentiate between a self-limiting seizure and dangerous status epilepticus. The nurse must record the start and end times to guide medical intervention.

C. Lowering the side rails during a seizure increases the risk of the client falling from the height of the bed. Standard seizure precautions require that side rails remain raised and should be padded to prevent blunt force trauma. Ensuring the patient stays within the safe boundaries of the bed is a primary safety goal.

D. Physical restraints can cause severe musculoskeletal injuries such as fractures or dislocations during the forceful involuntary movements of the clonic phase. Restricting the extremities creates unnecessary resistance against powerful muscle contractions. The nurse should clear the immediate area of hard objects rather than holding the client down.

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Correct Answer is D

Explanation

A) Rubella titer nonimmune: A nonimmune rubella titer indicates that the client is not immune to rubella, which is a common finding in many pregnant women. However, rubella vaccination is not given during pregnancy because the vaccine is a live virus. The client will typically be vaccinated postpartum. Follow-up would be required, but it is not an urgent concern during the pregnancy itself.

B) Negative varicella titer: A negative varicella titer means the client is not immune to chickenpox, which is a concern because varicella can cause serious complications during pregnancy. However, similar to rubella, the varicella vaccine is contraindicated during pregnancy, and vaccination would be given postpartum. This requires follow-up after delivery but does not require urgent intervention during the pregnancy.

C) Positive Rh factor: The Rh factor is a blood type characteristic, but what is typically more concerning is the Rh incompatibility, which occurs when a Rh-negative mother carries a Rh-positive baby. A positive Rh factor is not a problem for the client themselves but could be important if the father is Rh-positive. If there is concern for Rh incompatibility, the nurse would monitor for the development of Rh sensitization and administer Rh immunoglobulin (RhoGAM) if needed. This does not require urgent intervention unless Rh incompatibility is confirmed.

D) Positive serologic test for syphilis: A positive test for syphilis requires immediate follow-up intervention. Syphilis is a sexually transmitted infection that can cause serious complications during pregnancy, including miscarriage, stillbirth, preterm birth, and congenital syphilis. Treatment with penicillin is recommended to prevent transmission to the baby and to treat the infection in the mother. A positive serologic test for syphilis warrants prompt intervention.

A. Respiratory complaint B. Temperature C. Sputum characteristics D. Weight E. Blood pressure F. Oxygen saturation G. Travel history H. Heart rate

Correct Answer is ["A","B","C","D","G"]

Explanation

A. Respiratory complaint: A 4-day productive cough with fatigue and night sweats raises concern for a respiratory infection, including tuberculosis (TB) or pneumonia. Further evaluation, including chest imaging and sputum studies, is warranted.
B. Temperature: A low-grade fever (38.1°C/100.5°F) for several days, along with night sweats, suggests a possible infectious process, requiring further investigation.
C. Sputum characteristics: Blood-tinged sputum raises concern for TB, bronchitis, pneumonia, or malignancy, necessitating a sputum culture and acid-fast bacillus (AFB) testing.
D. Weight: Unintentional weight loss (5 lb in 1 week) and decreased appetite can indicate chronic infection, malignancy, or another systemic illness, necessitating further evaluation.
G. Travel history: Recent travel to South Africa, a country with a high TB prevalence, increases the risk of tuberculosis exposure and justifies further screening.
Incorrect Choices:
E. Blood pressure: 112/88 mm Hg is within the normal range and does not require further evaluation.
F. Oxygen saturation: 98% on room air is normal and does not indicate respiratory compromise.
H. Heart rate: 98/min is slightly elevated but could be due to fever or mild dehydration. It is not a primary concern.

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

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Correct Answer is D

Explanation

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Correct Answer is ["A","B","C","D","G"]

Explanation

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