After placing a client who is having a seizure in the side-lying position, which intervention should the nurse implement?
Apply soft restraints to all extremities.
Remove objects that could cause injury.
Place pillows around the client's head.
Administer oxygen per nasal cannula.
The Correct Answer is B
Choice A reason: Applying soft restraints to all extremities is not appropriate during a seizure as it can increase the risk of injury. The priority is to ensure the client's safety by preventing injury without restraining them.
Choice B reason: Removing objects that could cause injury is crucial. During a seizure, the client may move unpredictably, and any nearby objects could pose a risk of harm. Clearing the area ensures the client has a safe space to have the seizure without additional hazards.
Choice C reason: Placing pillows around the client's head can provide some protection, but it is not as immediately effective or necessary as removing potentially harmful objects from the surrounding area. Ensuring a clear and safe environment is the primary concern.
Choice D reason: Administering oxygen per nasal cannula is not the first priority during a seizure. While maintaining oxygenation is important, the immediate focus should be on ensuring the client's physical safety by removing dangerous objects. Once the seizure subsides, appropriate respiratory support can be provided if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Determining if the client is using an inhaler before exercising is the most immediate and relevant action. Inhalers, particularly bronchodilators, can help prevent exercise-induced bronchoconstriction by relaxing the airway muscles and reducing mucus production.
Choice B reason: Assessing the client for signs and symptoms of upper airway infection is important but may not be directly related to the episodes triggered by exercise. This action might be more appropriate if there are other indications of infection.
Choice C reason: Reviewing the client's routine asthma management prescriptions is a good practice, but it should come after addressing the immediate concern of managing exercise-induced symptoms. Ensuring proper inhaler use can have a more immediate impact.
Choice D reason: Teaching the client to use pursed-lip breathing when episodes occur is useful for managing dyspneal but does not address the prevention of exercise-induced bronchoconstriction as effectively as using an inhaler.
Correct Answer is B
Explanation
Choice A reason: The DASH eating plan does not recommend excluding grains from the daily diet. In fact, whole grains are an important part of the DASH diet.
Choice B reason: Enjoying fat-free yogurt as an occasional snack food aligns with the DASH diet's emphasis on low-fat dairy products. This behaviour indicates adherence to the dietary guidelines for reducing hypertension.
Choice C reason: Using lactose-free dairy products is not specifically related to the DASH diet. It may be relevant for individuals who are lactose intolerant, but it does not indicate adherence to the DASH diet principles.
Choice D reason: Carefully cleaning and peeling fresh fruits and vegetables is a good practice for food safety but does not specifically indicate adherence to the DASH diet. The DASH diet encourages the consumption of fruits and vegetables, but how they are cleaned and prepared is less relevant than the overall dietary choices.
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