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?

1. Lower the side rails of the bed when the seizure begins.
2. Measure the duration of the seizure.
3. Restrain the client's arms and legs to prevent injury.

Insert an oral airway into the client's mouth.

B. Herpes simplex is a viral infection that causes skin eruptions or lesions. To promote healing and prevent secondary infections, it is important to keep the affected area clean. Cleansing the skin eruptions with povidone-iodine, an antiseptic solution, can help reduce the risk of infection and promote healing.

The other options are incorrect:

A. Over-the-counter topical ointments are generally not recommended for the treatment of herpes simplex outbreaks. It is best to consult with a healthcare provider for appropriate medication and treatment options.

C.Herpes simplex is a viral infection, and antibiotics are used to treat bacterial infections. Antibiotics are not effective against viral infections like herpes simplex.

D. Placing disposable thermometers in the client's room is not directly related to the management of a herpes simplex outbreak. It is important to focus on interventions specific to the client's condition.

Explanation

D. Maintain the client in high-Flower’s position

Crackles in the bases of the lungs, shortness of breath, and an increased respiratory rate are signs of pulmonary congestion, which is commonly seen in heart failure. Maintaining the client in a high-Fowler's position, with the head of the bed elevated to a 45-60-degree angle, helps reduce venous return to the heart, decreases fluid accumulation in the lungs, and improves breathing comfort for the client.

The other options are not appropriate actions for the client's condition:

Instructing the client to cough every 4 hours in (option A) is not the priority action in this situation. Coughing may not effectively address the underlying cause of pulmonary congestion and may not provide immediate relief for the client.

Encouraging the client to ambulate to loosen secretions in (option B) is not the priority action in this situation. While ambulation can be beneficial for overall health, the client's symptoms of pulmonary congestion require immediate attention to improve respiratory status.

Increasing the client's intake of oral fluids in (option C) is not the priority action in this situation. While maintaining adequate hydration is important, excessive fluid intake can worsen the symptoms of heart failure and contribute to further fluid accumulation in the lungs.

Therefore, the nurse should maintain the client in high-Fowler's position (option D) to promote optimal lung function and improve breathing comfort. It is important to promptly notify the healthcare provider of the client's condition for further assessment and intervention.