A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?
Turn the client's head to the side.
Check the client's motor strength.
Document the time the seizure began.
Loosen the clothing around the client's waist.
The Correct Answer is A
Turn the client's head to the side.
The nurse should turn the client's head to the side first to prevent aspiration of oral secretions and maintain a patent airway. This is the priority action according to the airway, breathing, and circulation (ABC) principle.
Check the client's motor strength is wrong because it is not the priority action and it is not feasible during a seizure. The nurse should check the client's motor strength after the seizure to assess for any neurological deficits or postictal weakness.
Document the time the seizure began is wrong because it is not the priority action and it can be done later. The nurse should document the time, duration, type, and characteristics of the seizure, but only after ensuring the client's safety and well-being.
Loosen the clothing around the client's waist is wrong because it is not the priority action and it may not be necessary. The nurse should loosen any tight clothing that could impair breathing or circulation, but only after securing the airway and protecting the head from injury.
Turn the client's head to the side.
The nurse should turn the client's head to the side first to prevent aspiration of oral secretions and maintain a patent airway. This is the priority action according to the airway, breathing, and circulation (ABC) principle.
Check the client's motor strength is wrong because it is not the priority action and it is not feasible during a seizure. The nurse should check the client's motor strength after the seizure to assess for any neurological deficits or postictal weakness.
Document the time the seizure began is wrong because it is not the priority action and it can be done later. The nurse should document the time, duration, type, and characteristics of the seizure, but only after ensuring the client's safety and well-being.
Loosen the clothing around the client's waist is wrong because it is not the priority action and it may not be necessary. The nurse should loosen any tight clothing that could impair breathing or circulation, but only after securing the airway and protecting the head from injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Performing neurovascular checks with vital signs is an important action to take following a cardiac catheterization accessed through the femoral artery, as it can help monitor for complications such as bleeding, hematoma, infection, thrombosis, or embolism. The nurse should assess the color, temperature, sensation, movement, and pulses of the affected leg, as well as the blood pressure, heart rate, and oxygen saturation of the client.
Instructing the client to perform range-of-motion exercises to his lower extremities is not appropriate, as it can increase the risk of bleeding or dislodging the arterial sheath or closure device. The client should keep the affected leg straight and avoid bending or lifting it for several hours after the procedure, or as directed by the provider.
Restricting the client's fluid intake is not necessary, as fluid intake can help prevent dehydration and contrast- induced nephropathy following a cardiac catheterization. The client should be encouraged to drink fluids, unless contraindicated.
dAmbulating the client 1 hr following the procedure is not advisable, as it can cause bleeding, hematoma, or vascular injury. The client should remain on bed rest for 2 to 6 hours after the procedure, or as directed by the provider, and resume ambulation gradually and with assistance.
Correct Answer is A
Explanation
Aphasia is a language disorder that affects the ability to understand or produce speech. It can be caused by damage to the brain regions that control language, such as from a stroke. Depending on the type and severity of aphasia, the client may have difficulty with comprehension, expression, reading, or writing. Communication strategies for clients with aphasia include using nonverbal cues, such as gestures, facial expressions, pictures, or objects, to supplement verbal messages and enhance understanding.
The other options are not correct because:
a. "Use simple, childlike statements when speaking." This statement is incorrect because it is patronizing and disrespectful to the client. The client's cognitive and intellectual abilities are not affected by aphasia, only their language skills. The nurse should use simple and clear sentences, but not childish or demeaning ones.
c. "Use a higher-pitched tone of voice when speaking." This statement is incorrect because it is unnecessary and may be irritating to the client. The client's hearing is not affected by aphasia, only their language processing. The nurse should use a normal tone of voice and speak slowly and clearly.
d. "Ask multiple choice questions as part of the conversation." This statement is incorrect because it may be confusing and frustrating to the client. The client may have difficulty with verbal output or comprehension, and
multiple choice questions may add to their cognitive load. The nurse should ask yes or no questions or use gestures or pictures to elicit responses from the client.
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