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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Protein restriction is not universally indicated; specific dietary changes depend on the type of stones.
B. Ambulation is often encouraged to help pass stones and alleviate discomfort.
C. Applying cold compresses can be helpful for pain relief, but fluid intake is more critical for managing urolithiasis.
D. Increasing fluid intake to at least 3 L per day helps flush out stones and prevent new ones from forming.
Correct Answer is C
Explanation
A. While assessing perianal skin integrity is important for managing ulcerative colitis, it is not the immediate priority. Addressing electrolyte imbalances is crucial for stabilizing the client's condition first.
B. Emotional concerns are important but are secondary to addressing immediate physical health needs, such as electrolyte imbalances, which can be life-threatening if not managed promptly.
C. Reviewing electrolyte values is critical in an acute exacerbation of ulcerative colitis because diarrhea and fluid loss can lead to significant electrolyte imbalances, which need to be corrected to prevent complications.
D. Obtaining a dietary history is relevant for overall management but is not the immediate priority. Addressing electrolyte imbalances and hydration status is more urgent in acute exacerbations.
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