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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Using the overbed trapeze helps the client strengthen their upper body and improve mobility by allowing them to independently move and reposition themselves in bed. This promotes independence in activities of daily living and reduces reliance on nursing assistance.
Cautioning the client to avoid a prone position while in bed is important for preventing pressure ulcers and maintaining proper positioning, but it does not specifically promote independence and mobility.
Keeping a loose, absorbent dressing over the surgical site is important for wound care and infection prevention, but it does not directly promote mobility or independence. Maintaining abduction of the client's residual limb with a pillow is important to prevent contractures, but it does not directly promote mobility or independence.
Correct Answer is B
Explanation
Applying pressure with gauze helps to control bleeding and promote clotting. The other statements are not accurate or appropriate for circumcision care: "I will apply antibiotic ointment to my baby's penis" is not recommended for Plastibell circumcision. The use of antibiotic ointment is not typically necessary or recommended unless specifically advised by the healthcare provider.
"I will wipe away yellow crusts that form around the incision" should not be done as it may disrupt the healing process. Yellow crusts are a normal part of the healing process and should be left undisturbed.
"I will make sure that my baby's diaper is applied snugly" is unrelated to circumcision care. While proper diapering is important for maintaining hygiene, it does not specifically address the care of the circumcision site.
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