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 B
Explanation
A. "Are you feeling worse since taking the medication?" This is an important safety question to ask, as it helps to assess whether the client’s condition has worsened since starting the medication. However, it is not the first priority when evaluating the efficacy of a newly prescribed antidepressant.
B. "How long have you been taking the medication?" This is the most important question to ask first because the effectiveness of imipramine, a tricyclic antidepressant, can take several weeks to become apparent. If the client has not been taking the medication for an adequate period, the drug may simply not have had enough time to work yet.
C. "What time of day are you taking the medication?" While the timing of the medication can affect side effects, it is less critical than knowing how long the client has been on the medication when assessing its effectiveness.
D. "What dosage of medication are you taking?" This is an important follow-up question but not the first priority. The duration of treatment is more critical to assess before considering dosage adjustments.
Correct Answer is C
Explanation
A. Prothrombin level: Although checking coagulation levels like prothrombin time may be important, it is not the first-line diagnostic tool for determining the type of stroke (ischemic or hemorrhagic), which is critical for treatment decisions.
B. Chest x-ray: A chest x-ray is not directly related to diagnosing or determining the type of stroke. It may be used for other purposes, such as assessing for respiratory issues, but it is not the priority in stroke diagnosis.
C. Brain CT scan or MRI: A brain CT scan or MRI is the most crucial diagnostic test to perform before initiating treatment for a stroke. This imaging helps differentiate between ischemic and hemorrhagic stroke, guiding the appropriate treatment approach.
D. Lumbar puncture: A lumbar puncture may be used in certain neurological evaluations but is not the first-line test for diagnosing a stroke. It is invasive and not typically performed in the acute setting for stroke evaluation.
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