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

A.

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

B.

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

C.

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

D.

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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Related Questions

Correct Answer is A

Explanation

A. Hematologic spread: Hematologic spread (through the bloodstream) is a common mechanism for metastasis to distant organs like bones and liver. This is the most likely mechanism for the spread described.

B. Lymphatic circulation: Lymphatic spread often leads to regional lymph nodes rather than distant organs like bones and liver.

C. Invasion: Invasion involves local spread into adjacent tissues but does not typically account for distant metastasis.

D. Angiogenesis: Angiogenesis refers to the formation of new blood vessels to supply the tumor, not the mechanism by which cancer cells spread to distant sites.

Correct Answer is A

Explanation

A. "I am not on vacation. I am here with you." This response calmly reassures the client by affirming the mother’s presence, which helps address the son’s confusion without directly challenging his perception.

B. "How can I go on vacation? I do not have any money." This response could increase confusion and does not address the son's needs effectively. It could also lead to unnecessary discussions that might not be helpful.

C. "Stop saying that. You know better. No one told you that." This response is dismissive and confrontational, which may exacerbate the son’s distress and could damage the therapeutic relationship.

D. "Just forget about that and let's talk about something else." This response avoids addressing the son’s concerns, which can make him feel dismissed and not listened to, potentially worsening his symptoms.

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