A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:

Place the client on his back, remove dangerous objects, and insert a bite block.

Place the client on his side, remove dangerous objects, and insert a bite block.

Place the client on his back, remove dangerous objects, and hold down his arms.

Place the client on his side, remove dangerous objects, and protect his head.

Answer and Explanation

The Correct Answer is D

A. Place the client on his back, remove dangerous objects, and insert a bite block. Placing a client on their back during a seizure increases the risk of airway obstruction, and inserting a bite block is not recommended as it can cause injury.

B. Place the client on his side, remove dangerous objects, and insert a bite block. While positioning the client on their side is correct, inserting a bite block is contraindicated due to the risk of injury to the client.

C. Place the client on his back, remove dangerous objects, and hold down his arms. Restraining a client during a seizure is not recommended as it can cause injury. Placing the client on their back also poses a risk of airway obstruction.

D. Place the client on his side, remove dangerous objects, and protect his head. Positioning the client on their side helps maintain airway patency, removing dangerous objects prevents injury, and protecting the head helps prevent head trauma during the seizure.

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Correct Answer is B

Explanation

A. Assisting the client with meals: Assisting the client with meals is appropriate, as clients with dysphagia may need help to ensure safe swallowing and to avoid choking or aspiration.

B. Placing food on the affected side of the mouth: This is contraindicated because placing food on the affected side could increase the risk of choking or aspiration, as the client may not have adequate control over swallowing on the affected side.

C. Testing the gag reflex before offering food or fluids: Testing the gag reflex is appropriate for ensuring that the client has an intact protective reflex before eating or drinking, reducing the risk of aspiration.

D. Allowing ample time to eat: Allowing the client ample time to eat is important to prevent rushing, which could increase the risk of choking or aspiration. It ensures that the client can safely swallow their food.

A. "I wouldn't tell, if I were you." B. “In my experience, clients who know are more likely to be involved with their plan of care." C. "The shock of learning the diagnosis may be too much stress for an elderly person.” D. "This is a private concern that should include the physician, not me."

Correct Answer is B

Explanation

A. "I wouldn't tell if I were you." This response is inappropriate because it imposes the nurse's personal opinion rather than supporting the family in making an informed decision.

B. "In my experience, clients who know are more likely to be involved with their plan of care." This is the best response because it encourages transparency and patient autonomy, allowing the client to participate in their care decisions.

C. "The shock of learning the diagnosis may be too much stress for an elderly person.” This response is not based on evidence and may discourage the family from being honest with the client, which could prevent the client from making informed decisions.

D. "This is a private concern that should include the physician, not me." While the physician should be involved in the discussion, the nurse also plays a crucial role in providing support and guidance to the family. This response dismisses the nurse's role in the situation.

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A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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