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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Agranulocytosis: Carbamazepine carries a boxed warning for serious hematologic effects, including agranulocytosis and aplastic anemia. Agranulocytosis is a significant drop in white blood cell count, leading to a high risk of infection.
B. Birth defects: While carbamazepine is associated with birth defects when taken during pregnancy, the boxed warning specifically highlights the risk of severe blood disorders like agranulocytosis.
C. Skin rash: Carbamazepine can cause serious skin reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis, but the boxed warning focuses more on the hematologic risks.
D. Liver damage: Although carbamazepine can cause liver damage, this is not the primary focus of the boxed warning, which emphasizes hematologic effects.
Correct Answer is D
Explanation
A. Demonstrate empathy for the client by trying to mimic the client's state of anxiety. This is not appropriate as it could exacerbate the client’s anxiety rather than alleviate it. The nurse should remain calm and provide reassurance.
B. Tell the client that you must leave to go report his symptoms to the psychiatrist on duty. Leaving the client alone during a panic attack could increase their feelings of fear and isolation, worsening the situation.
C. Tell the client this is an acute exacerbation with a positive prognosis and low morbidity. While this information is correct, it does not directly address the client's immediate need for reassurance and safety during the panic attack.
D. Stay with the client, emphasizing that he is safe and that you will remain with him. This is the most appropriate intervention as it provides the client with a sense of safety and security, which is crucial during a panic attack.
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