A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take first?
Turn the client on their side.
Perform a neurologic check.
Obtain the client's vital signs.
Notify the rapid response team.
The Correct Answer is A
A. Turning the client on their side helps prevent aspiration (inhaling fluid or vomit into the lungs) and promotes drainage of oral secretions, reducing the risk of airway obstruction during the seizure.
B. While assessing neurological status is important, it should be done after ensuring the client's safety during the seizure. This can be done after the seizure has stopped.
C. While obtaining vital signs is important for assessing the client's overall condition, it is not the immediate priority during an active seizure. Vital signs can be assessed once the seizure has stopped and the client's safety has been ensured.
D. Notifying the rapid response team may be necessary if the seizure persists beyond a certain duration (status epilepticus) or if there are complications. However, the first action should be to ensure the client's immediate safety by turning them onto their side to prevent aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E","G"]
Explanation
Improvement in blood pressure would suggest better cardiovascular stability
A stable or decreased respiratory rate would indicate improved respiratory function and potentially reduced chest tightness.
An increase in oxygen saturation levels would indicate improved respiratory function and cardiovascular status.
A decrease in pain level would indicate improvement in the chest tightness and radiating pain experienced by the client.
A decrease in heart rate may indicate improved cardiovascular function and reduced stress on the heart.
Urinary output and echocardiogram results are not typically immediate indicators of improvement in the client's condition following an episode of chest tightness and radiating pain.
Correct Answer is B
Explanation
This response acknowledges the client's fear and invites them to express their concerns, allowing the nurse to address them effectively and provide necessary information or support.
A. This response focuses specifically on the fear of needles and may not address the client's overall apprehension about the procedure or their specific concerns.
C. This response directly asks the client to articulate their fears, which can help the nurse understand the specific reasons behind their anxiety and tailor their support and education accordingly.
D. While this response attempts to offer reassurance, it may come across as dismissive of the client's current fears and may not effectively address their concerns or provide the support they need before undergoing the procedure.
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