A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure.
Which of the following actions should the nurse take?
- Lower the side rails of the bed when the seizure begins.
- Measure the duration of the seizure.
- Restrain the client's arms and legs to prevent injury.
Insert an oral airway into the client's mouth.
Lower the side rails of the bed when the seizure begins.
Measure the duration of the seizure.
Restrain the client's arms and legs to prevent injury.
Insert an oral airway into the client's mouth.
The Correct Answer is B
Lowering the side rails of the bed could lead to the client falling from the bed. Instead raise the side rails and place padding on them.
Measuring the seizure duration is a crucial step for medical evaluation afterwards necessary for determining intervention.
Inserting an oral airway into the client's mouth is not indicated during a tonic-clonic seizure. It is generally not recommended to place any objects or devices into the mouth of a person having a seizure, as it can potentially cause injury to the person or damage to the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This statement reflects appropriate newborn care as newborns have sensitive skin, and using soap on the face can cause irritation. Washing the baby's face with a warm, wet washcloth is a gentle and effective way to clean the baby's face without the need for soap.
Moist towelettes may not be suitable for cleaning a newborn's head as they may contain chemicals or fragrances that can be harsh on the baby's delicate skin. It is generally recommended to use a soft, damp cloth for cleaning the baby's head.
Bathing a newborn under a faucet of running water can be unsafe as the water temperature may fluctuate and pose a risk of scalding. It is recommended to use a baby bathtub or a basin with warm water for bathing the baby.
Newborns do not need to be bathed daily as frequent bathing can strip their skin of natural oils and cause dryness. It is generally recommended to bathe newborns 2-3 times a week or as needed, focusing on areas that need cleaning such as the diaper area and skin folds.
Correct Answer is C
Explanation
Orthostatic hypotension, which is a sudden drop in blood pressure upon standing, can be a side effect of enalapril and may lead to syncope. Instructing the client to rise slowly from a sitting to a standing position helps minimize the risk of a sudden drop in blood pressure and decreases the chances of syncope occurring.
Decreasing fluid intake is not likely to be the cause of syncope related to enalapril. It is important for clients to maintain adequate hydration, especially if they are experiencing side effects such as orthostatic hypotension.
While a low pulse rate may indicate bradycardia, it is not the primary concern in this situation. Orthostatic hypotension leading to syncope is the main issue, and the client should be instructed to rise slowly to prevent it.
While enalapril is an angiotensin-converting enzyme (ACE) inhibitor that can increase potassium levels in the blood, it is not directly related to syncope. Dietary changes should be made under the guidance of a healthcare provider based on individual needs and blood test results.
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