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?

Check the client’s motor strength.

Turn the client’s head to the side.

Document the time the seizure began.

Loosen the clothing around the client’s waist.

Answer and Explanation

The Correct Answer is B

A: Checking the client’s motor strength is not the first priority during a seizure. Ensuring the client’s safety and airway patency is more important.

B: Turning the client’s head to the side is the first action. This helps maintain an open airway and prevents aspiration of saliva or vomit.

C: Documenting the time the seizure began is important for medical records but is not the immediate priority during the seizure.

D: Loosening the clothing around the client’s waist can help with comfort but is not the first action to take during a seizure.

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Correct Answer is B

Explanation

A: Restraining the client during a seizure is not recommended. It can cause injury to both the client and the person attempting to restrain them.

B: Moving objects away from the client is correct. This helps prevent injury by ensuring that the client does not hit or knock over objects during the seizure.

C: Placing the client on his back is not recommended. The client should be placed on their side to maintain an open airway and prevent aspiration.

D: Inserting a padded tongue blade into the client’s mouth is outdated and dangerous. It can cause injury to the client’s mouth and teeth. The focus should be on ensuring the client’s safety and maintaining an open airway.

A. “I will wear earphones during this test.” B. “A small probe is placed inside my ear.” C. “Small electrodes are placed on my scalp.” D. “A tuning fork is placed on my head.”

Correct Answer is D

Explanation

A: Wearing earphones is not part of the Rinne test. Earphones are used in other types of hearing tests, such as audiometry.

B: A small probe is not used in the Rinne test. Probes are used in other diagnostic procedures, such as tympanometry.

C: Small electrodes are not used in the Rinne test. Electrodes are used in tests like electroencephalography (EEG).

D: A tuning fork is placed on the mastoid bone behind the ear and then near the ear canal during the Rinne test. This test compares air conduction to bone conduction of sound.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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