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 B

Explanation

A. Generalized anxiety disorder: Generalized anxiety disorder involves persistent and excessive worry, but it does not typically present with the specific symptoms of nightmares and flashbacks related to trauma.

B. Posttraumatic stress disorder: PTSD is characterized by symptoms such as nightmares, flashbacks, and difficulty sleeping, especially following exposure to traumatic events. This fits the soldier’s presentation.

C. Obsessive-compulsive disorder: OCD involves recurrent, intrusive thoughts (obsessions) and/or repetitive behaviors (compulsions). The symptoms described do not align with OCD but rather with trauma-related symptoms.

D. Social phobia: Social phobia involves intense fear of social situations, not the trauma-related symptoms described. It is less relevant to the soldier’s experience of nightmares and flashbacks.

A. client's anxiety level decreased B. client's pain level decreased C. assessment completed D. client understood the importance of the assessment

Correct Answer is B

Explanation

A. client's anxiety level decreased: While reducing anxiety is important, it is not the initial priority when a client is experiencing physical pain that is affecting their ability to engage in the assessment.

B. client's pain level decreased: The initial desired outcome is to address the client's immediate physical pain. Once the pain is managed, the client will likely be better able to participate in the assessment and respond to questions about their mental health.

C. assessment completed: Completing the assessment is important, but it should not be prioritized over managing the client's immediate physical pain, which is currently hindering their ability to participate.

D. client understood the importance of the assessment: The client’s understanding of the assessment’s importance is less critical than addressing their immediate physical discomfort, which is a more pressing concern in this scenario.

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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

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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