A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?
"Place the client on his back."
"Restrain the client."
"Insert a padded tongue blade into the client's mouth."
"Move objects away from the client."
The Correct Answer is D
Moving objects away from the client is an important action to take during a seizure, as it can prevent injury and protect the client from harm.
"Place the client on his back." is not correct, as it can cause airway obstruction and aspiration. The client should be placed on his side, preferably in a lateral recumbent position, to allow saliva and secretions to drain from the mouth.
"Restrain the client." is not appropriate, as it can cause injury, increase agitation, or prolong the seizure. The client should be allowed to move freely during a seizure, but supported and guided away from hazards.
"Insert a padded tongue blade into the client's mouth." is not advisable, as it can cause oral trauma, choking, or damage to the teeth. The client should not have anything inserted into his mouth during a seizure, as he cannot swallow or bite his tongue. The nurse should ensure that the client's airway is clear and patent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The priority nursing action is to notify the provider of the client's allergy because shellfish allergy may indicate an allergy to iodine, which is commonly used as a contrast dye in cardiac catheterization. This could cause a severe allergic reaction or anaphylaxis during the procedure, which could be life-threatening. The provider may need to order a different type of contrast dye or premedicate the client with antihistamines or steroids to prevent an allergic reaction.
a. Ask the client if any other foods cause such a reaction is wrong because it is not the priority action and it does not address the potential risk of iodine allergy.
c. Notify the dietary department of the client's allergy is wrong because it is not relevant to the cardiac catheterization and it does not prevent an allergic reaction during the procedure.
d. Atach a wrist band indicating the client's allergy is wrong because it is not sufficient to alert the provider or the catheterization team of the client's allergy and it does not prevent an allergic reaction during the procedure.
Correct Answer is A
Explanation
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.
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