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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Random, rapid growth of the tumor: Benign tumors generally grow slowly and are less likely to invade nearby tissues. Rapid growth is more characteristic of malignant tumors.

B. Cells colonizing to distant body parts: Benign tumors do not metastasize to distant parts of the body; this is a feature of malignant tumors.

C. Tumor pressure against normal tissues: Even though benign tumors do not invade other tissues, they can still cause problems by pressing against surrounding normal tissues, potentially leading to significant functional issues depending on their location.

D. Emission of abnormal proteins: Abnormal protein emission is more relevant to malignancies that may cause paraneoplastic syndromes rather than benign tumors.

A. hypokalemia or hyponatremia. B. acute gastrointestinal bleed. C. increased intracranial pressure. D. respiratory depression.

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.

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A client is having a tonic-clonic seizure. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client is diagnosed with a benign brain tumor. Which of the following features of a benign tumor is of most concern to the nurse?

Correct Answer is C

Explanation

Paramedics have brought a patient to the emergency department with a suspected heroin overdose. The nurse should recognize that the patient's most acute threat to health at this time is:

Correct Answer is D

Explanation

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