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?

Document the time the seizure began.

Turn the client's head to the side.

Loosen the clothing around the client's waist.

Check the client's motor strength.

Answer and Explanation

The Correct Answer is B

A. Documenting the time of the seizure is important but is not the immediate priority. The priority is to ensure the client's safety during the seizure.

B. Turning the client's head to the side is the first action to take during a seizure. This helps prevent aspiration and keeps the airway clear by allowing any secretions to drain from the mouth.

C. Loosening clothing around the client's waist is important for comfort but should be done after ensuring the client's immediate safety. The primary focus should be on airway protection and preventing injury.

D. Checking the client's motor strength is not immediately relevant during an active seizure. The priority is to manage the seizure and ensure the client's safety, with detailed assessments to follow once the seizure has ended.

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Correct Answer is A

Explanation

A. Lowering the height of the solution container will slow the rate of instillation, reducing the intensity of the cramps and allowing the client to tolerate the enema better.
B. Encouraging the client to bear down may increase discomfort and is not recommended during the administration of an enema.
C. Allowing the client to expel some fluid before continuing might provide temporary relief but does not address the rate of fluid instillation, which is the primary cause of cramping.
D. Stopping the enema and documenting the intolerance is not the first step; adjusting the rate of administration should be tried first to help the client tolerate the procedure.

A. Lower right quadrant B. Upper right quadrant C. Upper left quadrant D. Lower left quadrant

Correct Answer is D

Explanation

A. Lower right quadrant pain is often associated with appendicitis or other conditions, not typically diverticular disease.
B. Upper right quadrant pain is usually related to liver, gallbladder, or duodenal issues.
C. Upper left quadrant pain is more common with conditions like gastritis or pancreatic disorders.
D. Lower left quadrant pain is characteristic of diverticular disease, particularly diverticulitis, where inflammation occurs in the sigmoid colon.

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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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Explanation

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Explanation

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