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 B
Explanation
Correct answer: B
A. Place no more than one small pillow in the crib
The American Academy of Pediatrics (AAP) recommends that infants should sleep on a firm and flat surface without any pillows, blankets, or soft bedding. These items can pose a suffocation risk.So, the nurse should advise against using any pillows in the crib.
B. This is agood recommendation. Bibs can be a choking hazard during sleep.Removing them ensures the baby’s safety and reduces the risk of accidental suffocation
C. Making sure the crib mattress is soft in (option C) is not recommended. The crib mattress should be firm to provide a safe sleeping surface for the infant. Soft mattresses can increase the risk of suffocation.
D. Starting to use a highchair for feedings at 3 months old in (option D) is not typically necessary or developmentally appropriate. At this age, infants are typically fed while being held in a caregiver's arms or in a reclined position, such as in a baby bouncer or supported seat.
Correct Answer is C
Explanation
Elevating the head of the bed while sleeping is a recommended strategy for managing GERD (gastroesophageal reflux disease). By raising the head of the bed, gravity helps to prevent stomach acid from flowing back into the esophagus, reducing the likelihood of acid reflux and associated symptoms.
"You should eat three large meals and two snacks per day" is not recommended for GERD management. Instead, it is advised to have smaller, more frequent meals throughout the day to reduce the pressure on the stomach and minimize the likelihood of acid reflux.
"You should lay down for 1 hour following a meal" is not recommended for GERD management. It is advised to avoid lying down immediately after meals, as this can increase the risk of acid reflux. It is generally recommended to wait at least 2 to 3 hours before lying down.
"You should only drink 2 cups of coffee per day" is a specific recommendation related to caffeine intake, which can potentially trigger or worsen GERD symptoms in some individuals. However, this statement alone does not encompass the comprehensive dietary recommendations for managing GERD.
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