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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While high-fiber foods are generally healthy, they are not specifically targeted to prevent biliary colic. The primary dietary focus should be on fat intake.
B. Avoiding foods high in fat is crucial for clients with chronic cholecystitis, as fatty foods can trigger biliary colic by stimulating the gallbladder to contract.
C. High sodium intake is more related to cardiovascular and kidney health and is not specifically implicated in biliary colic.
D. Including foods high in starch and proteins is not as critical as avoiding fatty foods to prevent episodes of biliary colic.
Correct Answer is A
Explanation
A. Pain management is crucial after amputation, and the client should be informed that postoperative pain may gradually decrease, though some level of discomfort can persist.
B. A tingling sensation is not always expected, and the client should be prepared for a range of sensations postoperatively, including phantom pain.
C. Phantom pain is a real phenomenon experienced by many individuals following an amputation; it is not purely psychological.
D. Pain management strategies should be discussed, and the client should be aware that pain may not disappear immediately and may require ongoing management.
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