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?
Place a pillow under the client's head.
Gently restrain the client's extremities.
Apply a face mask for oxygen administration.
Insert a padded tongue blade into the client's mouth.
The Correct Answer is A
- Place a pillow under the client's head.
The nurse should place a pillow under the client's head to protect it from injury during the seizure. The nurse should also loosen any tight clothing, remove any objects that could harm the client, and maintain a patent airway.
- Gently restrain the client's extremities is wrong because it can cause injury to the client or the nurse. The nurse should not restrain or interfere with the client's movements during the seizure, but rather ensure a safe environment and observe the seizure activity.
- Apply a face mask for oxygen administration is wrong because it can be dislodged by the client's movements and pose a choking hazard. The nurse should not atempt to insert anything into the client's mouth or nose during the seizure, but rather provide oxygen by nasal cannula after the seizure if needed.
Insert a padded tongue blade into the client's mouth is wrong because it can damage the client's teeth, gums, or tongue, or cause aspiration or airway obstruction. The nurse should not atempt to insert anything into the client's mouth or nose during the seizure, but rather turn the client to a side-lying position after the
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should identify that this client has multiple risk factors for cardiovascular disease, such as hypertension, obesity, and smoking. These factors can increase the risk of atherosclerosis, coronary artery disease, stroke, and peripheral vascular disease.
Depression is wrong because it is not directly related to the client's physical examination findings. Depression may have other risk factors, such as genetics, stress, trauma, or substance abuse.
Thyroid disease is wrong because it is not directly related to the client's physical examination findings. Thyroid disease may have other risk factors, such as autoimmune disorders, iodine deficiency, or radiation exposure.
Testicular cancer is wrong because it is not directly related to the client's physical examination findings. Testicular cancer may have other risk factors, such as cryptorchidism, family
Correct Answer is D
Explanation
A headache is a common and expected adverse effect of nitroglycerin, due to its vasodilating action. The client can take an over-the-counter analgesic to relieve the headache, unless contraindicated.
"A headache is an indication of an allergy to the medication." is not correct, as a headache is not a sign of an allergic reaction to nitroglycerin. An allergic reaction would manifest as rash, itching, swelling, or difficulty breathing.
"A headache indicates tolerance to the medication." is not accurate, as a headache does not indicate tolerance to nitroglycerin. Tolerance would manifest as reduced or absent relief from anginal pain.
"A headache is likely due to the anxiety about the chest pain." is not plausible, as a headache is not likely due to the anxiety about the chest pain. Anxiety would manifest as nervousness, restlessness, palpitations, or sweating.
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