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
feet or toes that occurs at night and is not relieved by rest.
Correct Answer is C
Explanation
Choice A reason:
This statement is incorrect because it trivializes the patient's concerns and implies that enjoyment is the primary goal, which is not the case. The main purpose of cardiac rehabilitation is to improve health outcomes, not just to make the routine enjoyable.
Choice B reason:
While exercise is beneficial for heart health, this statement is too general and does not address the specific benefits of cardiac rehabilitation for someone who has had a myocardial infarction.
The correct answer is C:
"Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely." Cardiac rehabilitation is crucial for patients who have experienced a myocardial infarction. It provides a structured program that includes exercise, education, and support to help patients improve their cardiovascular health and prevent future cardiac events.
Choice D reason:
Deferring to the doctor's expertise does not educate the patient about the benefits of cardiac rehabilitation. It's important for patients to understand why they are participating in the program.
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