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 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.

A. Reduce the client's intake of protein. B. Restrict the client's intake of fluids. C. Administer vitamin K D. Administer diuretics.

Correct Answer is A

Explanation

A. Reducing protein intake is a key intervention to decrease ammonia levels in clients with liver cirrhosis and encephalopathy. Protein metabolism in the liver produces ammonia, and limiting protein can help manage elevated ammonia levels, thereby reducing symptoms of encephalopathy.

B. Restricting fluid intake is not directly related to decreasing ammonia levels. While fluid restriction may be necessary in cases of ascites or edema, it does not address the root cause of elevated ammonia in liver disease.

C. Administering vitamin K is important for managing clotting issues in liver disease but does not directly impact ammonia levels. Vitamin K helps with clotting factor synthesis, which is not directly related to ammonia metabolism.

D. Administering diuretics can help manage fluid retention but does not reduce ammonia levels. The primary goal for managing ammonia in cirrhosis involves dietary modifications and medications like lactulose, rather than diuretics.

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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?

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Naxlex Comprehensive Predictor Exams

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