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 A
Explanation
A. Hemorrhagic stroke is often associated with a sudden, severe headache, high blood pressure, and neurological symptoms such as seizures and vomiting due to the rupture of a blood vessel in the brain.
B. Thrombotic stroke is typically characterized by the gradual onset of symptoms due to a clot forming in an artery supplying the brain, not usually presenting with sudden severe headache and vomiting.
C. Transient ischemic attack (TIA) presents with temporary neurological symptoms that resolve within 24 hours and does not usually involve seizures, severe headache, or significantly elevated blood pressure.
D. Embolic stroke occurs when a blood clot travels to the brain, leading to sudden onset of symptoms, but it is less commonly associated with the severe headache, vomiting, and hypertension seen in hemorrhagic stroke.
Correct Answer is C
Explanation
A. While pain management may be necessary, it is not the priority in the initial management of a snake bite. The focus should be on addressing the potential spread of venom.
B. Discharging the client is not appropriate as the client requires immediate medical evaluation and treatment due to the venomous snake bite.
C. Removing the elastic bandages is crucial as they can impede blood flow and potentially exacerbate the spread of venom. Elastic bandages should not be used to constrict the limb; proper medical treatment is needed.
D. Obtaining a prescription for anti-venom is important but should be done after initial assessment and treatment of the snake bite. Removing constrictive bandages is the immediate action to take to manage the bite effectively.
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