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.

Answer and Explanation

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

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Correct Answer is B

Explanation

The correct answer is B

Choice B reason: Intermittent claudication

Intermittent claudication is a characteristic symptom of PAD in the early stage, due to the reduced blood flow to the muscles during exercise. It is a cramping pain in the legs that occurs with walking and is relieved by rest.

Choice A reason: Dependent rubor is a sign of PAD in the advanced stage, due to the impaired vasodilation and reactive hyperemia. It is a reddish color of the lower extremities that occurs when they are lowered and disappears when they are elevated.

Choice C reason: Foot ulcers are a complication of PAD in the late stage, due to the poor wound healing and tissue necrosis. They are usually located on the toes, heels, or pressure points.

Choice D reason: Rest pain is another sign of PAD in the late stage, due to the severe ischemia and nerve damage. It is a persistent pain in the feet or toes that occurs at night and is not relieved by rest.

A. Place a moist heating pad under the client's feet. B. Increase the client's oral ﬂuid intake. C. Obtain a pair of slipper-socks for the client. D. Rub the client's feet briskly for several minutes.

Correct Answer is C

Explanation

Obtaining a pair of slipper socks for the client is a simple and safe way to provide warmth and insulation to the feet, which can improve blood ﬂow and comfort.

Placing a moist heating pad under the client's feet is not recommended, as it can cause burns, vasodilation, or increased ﬂuid loss, which can worsen the condition.

Increasing the client's oral ﬂuid intake is not relevant, as it does not aﬀect the temperature or circulation of the feet.

Rubbing the client's feet briskly for several minutes is not advisable, as it can cause trauma, inﬂammation, or ulceration to the fragile skin and tissues of the feet.

Obtaining a pair of slipper socks for the client is a simple and safe way to provide warmth and insulation to the feet, which can improve blood ﬂow and comfort.

Placing a moist heating pad under the client's feet is not recommended, as it can cause burns, vasodilation, or increased ﬂuid loss, which can worsen the condition.

Increasing the client's oral ﬂuid intake is not relevant, as it does not aﬀect the temperature or circulation of the feet.

Rubbing the client's feet briskly for several minutes is not advisable, as it can cause trauma, inﬂammation, or ulceration to the fragile skin and tissues of the feet.

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