A nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic-clonic seizure. Which of the following interventions 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.

Keep the client in a supine position.

Answer and Explanation

The Correct Answer is B

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

This intervention is not recommended. Placing any object, including a padded tongue blade, into the mouth of someone experiencing a seizure poses a risk of injury, such as biting the tongue or breaking teeth. It can also obstruct the airway and increase the risk of aspiration. Therefore, inserting anything into the client's mouth during a seizure is contraindicated.

B. Place a pillow under the client's head.

Placing a pillow under the client's head can help prevent head injury by providing cushioning and support. It can also help maintain the client's airway and reduce the risk of aspiration. Therefore, this intervention is appropriate and helps ensure the client's safety during the seizure.

C. Gently restrain the client's extremities.

Restraining the client's extremities is not recommended during a seizure. It can increase the risk of injury, such as fractures or dislocations, and may exacerbate muscle contractions. It's important to allow the client's movements to occur naturally while taking measures to ensure their safety, such as removing nearby objects and providing a safe environment.

D. Keep the client in a supine position.

It is essential to ensure that the client's head is turned to the side (recovery position) to prevent aspiration and allow for drainage of oral secretions. Additionally, the nurse should remove any nearby objects that could pose a risk of injury during the seizure.

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Correct Answer is C

Explanation

A. "I will notify my provider before taking any other medications."

This statement demonstrates understanding of the importance of consulting the provider before taking any other medications. It is correct because phenytoin may interact with other drugs, so notifying the provider is essential to avoid potential interactions.

B. "I have made an appointment to see my dentist next week."

This statement indicates that the client understands the importance of dental care while taking phenytoin. Phenytoin can cause gum overgrowth (gingival hyperplasia), so regular dental check-ups are recommended to monitor oral health. This statement is correct.

C. "I will take this medication with meals."

This statement suggests that the client plans to take phenytoin with meals. However, phenytoin should generally be taken on an empty stomach to enhance absorption, unless gastrointestinal upset occurs. Therefore, this statement indicates a need for further teaching.

D. "I'll be glad when my seizures stop so I can quit taking this medicine."

This statement reflects a misconception about the management of epilepsy. Phenytoin is typically used as a long-term treatment to prevent seizures, not as a short-term solution to stop seizures. Therefore, this statement indicates a need for further education about the chronic nature of epilepsy and the need for ongoing medication adherence.

E. “I’ll take this medication before meals.”

This statement correctly indicates the timing of phenytoin administration before meals. Taking phenytoin before meals helps enhance absorption and minimize the risk of gastrointestinal side effects. Therefore, this statement is correct.

A. Hyperglycemia B. Hunger C. Hypoglycemia D. Pupil dilation

Correct Answer is C

Explanation

A. Hyperglycemia:

Hyperglycemia refers to high blood sugar levels. While certain medications can affect glucose metabolism and potentially lead to hyperglycemia as a side effect, this is not typically associated with hydantoin therapy for seizure disorder. Therefore, it is less likely for the patient to experience hyperglycemia as a direct result of taking hydantoin medication.

B. Hunger:

Hunger is not a common side effect of hydantoin therapy for seizure disorder. While some medications may affect appetite or cause changes in eating habits, hunger is not a typical side effect of hydantoin medications such as phenytoin.

C. Hypoglycemia:

Hypoglycemia refers to low blood sugar levels, which can lead to symptoms such as confusion, dizziness, sweating, and weakness. Hydantoin medications, particularly phenytoin, can affect glucose metabolism and increase the risk of hypoglycemia, especially in patients who already have diabetes or are prone to low blood sugar. Therefore, it is important for patients taking hydantoin therapy to monitor their blood sugar levels regularly and be aware of the signs and symptoms of hypoglycemia.

D. Pupil dilation:

Pupil dilation, or mydriasis, is not a common side effect of hydantoin therapy for seizure disorder. While certain medications may affect pupil size, this is not typically associated with hydantoin medications such as phenytoin.

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

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