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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Cytotoxic hypersensitivity is a type of hypersensitivity that involves the production of IgG or IgM antibodies that bind to antigens on the surface of cells, leading to cell destruction by complement activation or antibody-dependent cellular cytotoxicity. Myasthenia gravis is an example of a cytotoxic hypersensitivity, as it is caused by autoantibodies that target the acetylcholine receptors on the muscle cells, impairing neuromuscular transmission and causing muscle weakness.

Delayed hypersensitivity is a type of hypersensitivity that involves the activation of T cells and macrophages, leading to inﬂammation and tissue damage after several hours or days of exposure to an antigen. Examples of delayed hypersensitivity include contact dermatitis, tuberculin skin test, and transplant rejection.

Immediate hypersensitivity is a type of hypersensitivity that involves the production of IgE antibodies that bind to mast cells or basophils, leading to degranulation and release of histamine and other mediators, causing anaphylaxis, urticaria, or allergic rhinitis within minutes of exposure to an antigen.

Immune complex-mediated hypersensitivity is a type of hypersensitivity that involves the formation of antigen- antibody complexes that deposit in tissues or blood vessels, leading to complement activation and inﬂammation, causing vasculitis, glomerulonephritis, or serum sickness within hours or days of exposure to an antigen.

A. Place a pillow under the client's head. B. Gently restrain the client's extremities. C. Apply a face mask for oxygen administration. D. Insert a padded tongue blade into the client's mouth.

Correct Answer is A

Explanation

Place a pillow under the client's head.

The nurse should place a pillow under the client's head to protect it from injury during the seizure. The nurse should also loosen any tight clothing, remove any objects that could harm the client, and maintain a patent airway.

Gently restrain the client's extremities is wrong because it can cause injury to the client or the nurse. The nurse should not restrain or interfere with the client's movements during the seizure, but rather ensure a safe environment and observe the seizure activity.
Apply a face mask for oxygen administration is wrong because it can be dislodged by the client's movements and pose a choking hazard. The nurse should not atempt to insert anything into the client's mouth or nose during the seizure, but rather provide oxygen by nasal cannula after the seizure if needed.

Insert a padded tongue blade into the client's mouth is wrong because it can damage the client's teeth, gums, or tongue, or cause aspiration or airway obstruction. The nurse should not atempt to insert anything into the client's mouth or nose during the seizure, but rather turn the client to a side-lying position after the

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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?

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Naxlex Comprehensive Predictor Exams

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