A client that the nurse is caring for experiences a seizure. What would be a priority nursing action?
Restrain the client during the seizure.
Protect the client from injury.
Suction the mouth during the convulsion.
Insert a tongue blade between the teeth.
The Correct Answer is B
During a seizure, the nurse's priority is to ensure the client's safety by protecting them from injury. The nurse should loosen any tight clothing and move furniture or objects that may harm the client. The client should be turned onto their side to prevent aspiration, and suctioning the mouth is not indicated during the seizure. Restraints are not appropriate during a seizure, and inserting a tongue blade between the teeth can cause injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Ringing in the ears. Salicylate toxicity or salicylism is a condition that occurs when a client is taking large amounts of salicylates, which can result in symptoms such as tinnitus or ringing in the ears, nausea, vomiting, and diarrhea. Clients should report these symptoms to their healthcare provider immediately to prevent further complications.
Choice A, diarrhea, is not a symptom of salicylate toxicity, but rather a potential side effect of the medication in normal doses.
Choice C, dry eyes, and choice D, dry hacking cough, are not symptoms of salicylate toxicity.
Correct Answer is A
Explanation
Giving non-prescription laxatives to a client with cirrhosis can cause severe dehydration and electrolyte imbalances, which can be life-threatening. The nurse should report this intervention immediately to the physician.
Choice B is incorrect because measuring abdominal girth is a standard nursing intervention for clients with cirrhosis to assess for ascites.
Choice C is incorrect because asking the client about food intake is a standard nursing intervention for assessing nutritional status.
Choice D is incorrect because checking for signs of hepatic encephalopathy is a standard nursing intervention for clients with cirrhosis.
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