A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

Insert a padded tongue blade into the client's mouth.

Place a pillow under the client's head

Gently restrain the client's extremities.

Apply a face mask for oxygen administration

Answer and Explanation

The Correct Answer is B

A. Insert a padded tongue blade into the client's mouth: Inserting a tongue blade can cause harm, such as damaging the client's teeth or mouth or causing them to bite down on the blade, leading to injury. It is not recommended during a seizure.

B. Place a pillow under the client's head: Placing a pillow under the client’s head helps protect it from injury during the clonic phase of a seizure. This is the most appropriate and safest action to prevent head trauma while the client is experiencing a seizure.

C. Gently restrain the client's extremities: Restraint during a seizure can lead to injury and should be avoided. The priority is to allow the seizure to occur without interference, ensuring the client’s safety by preventing injury from the environment.

D. Apply a face mask for oxygen administration: Oxygen may be indicated if the client shows signs of respiratory distress, but applying a face mask immediately is not the priority. Ensuring safety during the seizure (e.g., protecting the head) is more important in the initial response.

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Correct Answer is D

Explanation

A. Supraventricular Tachycardia (SVT): SVT is a rapid rhythm, typically 150-250 bpm, where P waves are often absent, abnormal, or hidden. The rate in this strip is 70 bpm, and clear P waves are present.

B. Sinus Bradycardia: Sinus bradycardia is characterized by a heart rate below 60 beats per minute. The heart rate in this strip is 70 bpm, which is not bradycardic.

C. Sinus Tachycardia: Sinus tachycardia is characterized by a heart rate greater than 100 beats per minute. The heart rate in this strip is 70 bpm, which is not tachycardic.

D. Normal Sinus Rhythm: The EKG strip demonstrates a regular rhythm with a heart rate between 60 and 100 beats per minute, and a normal P wave preceding every QRS complex, all consistent with the criteria for Normal Sinus Rhythm.

A. Fidelity B. Justice C. Autonomy D. Veracity

Correct Answer is C

Explanation

A. Fidelity: Fidelity refers to being loyal, faithful, and keeping promises. While it is an important ethical principle in nursing, it does not directly relate to respecting the client's right to make decisions about their own care, as autonomy does.

B. Justice: Justice in healthcare refers to the fair and equitable distribution of resources and care. While important in general healthcare, it is not the primary ethical principle violated when a competent client's wishes to refuse treatment are disregarded.

C. Autonomy: Autonomy is the ethical principle that respects a person's right to make their own decisions, including the decision to discontinue ventilator support. If the nurse continues treatment against the client’s wishes, it would violate the principle of autonomy, which emphasizes respecting the patient’s decisions regarding their healthcare.

D. Veracity: Veracity refers to truthfulness and the obligation to provide honest information. While important, it does not directly apply to the situation where a patient wishes to discontinue treatment. The issue here is about respecting the patient’s decision (autonomy).

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A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You note the cardiac electrical rhythm below (see 6-second EKG strip). Which of the following would BEST describe the client's rhythm?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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