A nurse is out in public when an individual suddenly falls to the ground with a generalized tonic- clonic (grand mal) seizure.
Which action should the nurse take first?
Place a stick in the person’s mouth to prevent biting of the tongue and call for assistance.
Completely record time of the person’s seizure and save for paramedics.
Restrain the limbs to prevent injury while providing as much privacy for the person as possible.
Loosen the individual’s necktie after placing the person in the recovery position.
The Correct Answer is D
This is because the recovery position helps maintain the airway and prevent aspiration, and loosening the necktie prevents breathing restriction.
The other choices are wrong because:
Choice A is wrong because placing a stick or any object in the person’s mouth can cause injury to the teeth, gums, tongue or jaw and obstruct the airway. The person cannot swallow or bite their tongue during a seizure.
Choice B is wrong because recording the time of the seizure is not the first priority. The first priority is to ensure the safety and comfort of the person.
Choice C is wrong because restraining the limbs can cause injury or fracture, increase agitation and prolong the seizure. The nurse should protect the person from injury by moving furniture away and padding the head.
Normal ranges for seizure duration are usually less than 5 minutes for generalized tonic-clonic seizures and less than 15 seconds for absence seizures. If the seizure lasts longer than 5 minutes, or if the person has repeated seizures without regaining consciousness, it is considered a medical emergency and requires immediate treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A client who grimaces during a dressing change is showing a nonverbal sign of pain. Grimacing is an expression of facial muscles that indicates discomfort or distress.
The nurse should record this as a symptom of pain and ask the client to rate the pain using a numeric or visual scale.
Choice B is wrong because an elevated heart rate while exercising is not necessarily a symptom of pain. It could be a normal response to increased physical activity or a sign of other conditions such as anxiety, dehydration, or fever.
Choice C is wrong because crying during a procedure is not a reliable indicator of pain. Crying is an emotional response that can be influenced by many factors such as fear, stress, or sadness.
The nurse should not assume that the client is in pain based on crying alone and should ask the client about the reason for crying and the level of pain.
Choice D is wrong because saying “I feel achy all over” is not a specific description of pain.
Aching is a vague term that can refer to different sensations such as soreness, stiffness, or cramping.
The nurse should ask the client to clarify what kind of pain they are feeling, where it is located, how severe it is, and what makes it better or worse.
Correct Answer is D
Explanation
Independent. An independent nursing intervention is an action that a nurse can perform by themselves, without any management from a doctor or another discipline.
Taking the client’s temperature again is an example of an independent nursing intervention because it does not require a physician’s order or collaboration with other health care professionals.
Choice A is wrong because an interdependent nursing intervention is an action that requires collaboration or consultation with other health care professionals.
Taking the client’s temperature again does not involve working with other disciplines.
Choice B is wrong because a dependent nursing intervention is an action that requires an order from a physician or another health care provider.
Taking the client’s temperature again does not require a physician’s order.
Choice C is wrong because a collaborative nursing intervention is an action that involves working with other health care professionals to provide patient care.
Taking the client’s temperature again does not require collaboration with other disciplines.
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