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 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.

A. Renal dysfunction B. Pancreatic impairment C. Increased gastric motility D. Increased blood volume

Correct Answer is A

Explanation

A: Renal dysfunction is common in older adults and can lead to decreased clearance of medications from the body, increasing the risk of toxicity. Monitoring for signs of toxicity is crucial in this population.

B: Pancreatic impairment can affect digestion and insulin production but is not the primary reason for monitoring medication toxicity in older adults.

C: Increased gastric motility is not typically associated with aging. In fact, decreased gastric motility is more common and can affect drug absorption.

D: Increased blood volume is not a common physiological change in older adults. Decreased renal function and changes in body composition are more relevant factors affecting medication metabolism and excretion.

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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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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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