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 D
Explanation
Stopping dialysis is a significant decision made by the client, and it is important for the nurse to respect and support the client's autonomy and right to make decisions about their own healthcare. The nurse should provide emotional support, validate the client's feelings and concerns, and ensure that the client has access to appropriate resources and support systems. It is not the nurse's role to persuade or encourage the client to continue or reconsider the decision.
The other options are incorrect:
Tell the client she should discuss this decision with her family: While family involvement and support are important, the decision to stop dialysis ultimately rests with the client. It is the client's decision to make, and the nurse should respect the client's autonomy.
Discuss alternative treatment methods with the client: If the client has made an informed decision to stop dialysis, it is not appropriate for the nurse to discuss alternative treatment methods at this point. The focus should be on supporting the client in their decision and providing comfort and care.
Ask the facility chaplain to visit the client: Spiritual and emotional support can be valuable for clients facing end-of-life decisions, but it should be based on the client's preferences and requests. The nurse can offer spiritual support if desired but should not assume that it is necessary or appropriate in every case.
Correct Answer is C
Explanation
Informed consent is a legal and ethical requirement for certain medical procedures. It involves providing the client with clear and comprehensive information about the procedure, including its risks, benefits, alternatives, and expected outcomes. The client must understand the information provided and voluntarily give their consent before the procedure can be performed.
Placement of a central venous catheter is an invasive procedure that carries risks and potential complications, making it necessary to obtain informed consent from the client.
Wound irrigation with an antibiotic solution is a standard nursing intervention for wound care and does not usually involve invasive procedures. Informed consent is not typically required for this procedure.
The administration of an iron injection using the Z-track technique is a standard nursing procedure. While it involves an injection, it is not typically considered an invasive procedure that would require informed consent.
Insertion of a nasogastric tube is a common procedure that involves passing a tube through the nose and into the stomach for various purposes, such as feeding, decompression, or medication administration. While it is an invasive procedure, it is often performed in emergency or critical care situations where the client's immediate well-being takes precedence. Informed consent may not be feasible or necessary in these situations, depending on the context and urgency.
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