A client is having a tonic-clonic seizure. What should the nurse do first?
Elevate the head of the bed.
Restrain the client's arms and legs.
Place a tongue blade in the client's mouth.
Take measures to prevent injury.
The Correct Answer is D
A. Elevate the head of the bed: Elevating the head of the bed is not the priority during a seizure. The primary concern is ensuring the client's safety by preventing injury.
B. Restrain the client's arms and legs: Restraining a client during a seizure is not advised, as it can cause injury. Instead, the focus should be on protecting the client from harm.
C. Place a tongue blade in the client's mouth: Placing anything in the client’s mouth during a seizure is contraindicated, as it can lead to airway obstruction or injury.
D. Take measures to prevent injury: The priority during a seizure is to protect the client from injury by ensuring a safe environment, such as padding the head and moving any dangerous objects away.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Hypokalemia or hyponatremia: While electrolyte imbalances are important, they are not the most immediate threat in the context of a heroin overdose.
B. Acute gastrointestinal bleed: An acute gastrointestinal bleed is not a primary concern with heroin overdose. It is not the most acute threat in this scenario.
C. Increased intracranial pressure: Increased intracranial pressure is not directly related to heroin overdose. The most pressing issue is related to the effects of the overdose.
D. Respiratory depression: Heroin overdose commonly leads to respiratory depression, which is the most immediate and life-threatening condition. Addressing respiratory depression is crucial for patient survival.
Correct Answer is D
Explanation
A. Offer the client fluids with meals. Offering fluids with meals may decrease the client's appetite by creating a sense of fullness, which could further reduce calorie intake and not aid in weight gain.
B. Increase fiber in the client's diet. While fiber is important for digestive health, it may also contribute to a feeling of fullness and might not directly help in increasing body weight in clients with anorexia.
C. Encourage the client to eat less protein. Protein is essential for maintaining muscle mass and overall health, especially in clients with AIDS. Reducing protein intake would not be beneficial for weight gain or health maintenance.
D. Provide supplemental vitamins and supplemental nutrition. Offering supplemental nutrition and vitamins can help increase caloric intake and ensure that the client receives essential nutrients to support weight gain and overall health. This is the most appropriate action to help increase the client's body weight.
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