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.

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

Apply a face mask for oxygen administration.

Gently restrain the client’s extremities.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Place a pillow under the client’s head: During a tonic-clonic seizure, it is crucial to protect the client’s head from injury. Placing a pillow or any soft object under the head can help prevent head trauma caused by the convulsions. Ensuring the client’s safety by protecting their head is a primary concern during a seizure.

Choice B reason:

Insert a padded tongue blade into the client’s mouth: This action is incorrect and potentially dangerous. Inserting any object into the mouth during a seizure can cause injury to the teeth, gums, or jaw. It can also obstruct the airway. The myth that a person can swallow their tongue during a seizure is false, and no object should be placed in the mouth.

Choice C reason:

Apply a face mask for oxygen administration: While providing oxygen can be beneficial after the seizure has ended, during the seizure, the priority is to ensure the client’s safety and prevent injury. Applying a face mask during the active phase of a seizure is not practical and can interfere with managing the seizure safely.

Choice D reason:

Gently restrain the client’s extremities: Restraining the client’s extremities during a seizure is not recommended. Attempting to restrain the movements can cause injury to both the client and the nurse. The focus should be on protecting the client from harm without restricting their movements.

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Correct Answer is C

Explanation

Choice A reason:

Distorted perceptual field is more commonly associated with severe anxiety or panic attacks rather than moderate anxiety. In severe anxiety, a person’s ability to perceive reality can be significantly impaired, leading to distorted perceptions and an inability to focus.

Choice B reason:

Urinary frequency can be a symptom of anxiety, but it is not specifically indicative of moderate anxiety. It can occur in various levels of anxiety, including mild, moderate, and severe. However, it is not as prominent a symptom as others like rapid speech or restlessness.

Choice C reason:

Rapid speech is a common symptom of moderate anxiety. Individuals with moderate anxiety often exhibit signs of increased nervousness and agitation, which can manifest as rapid or pressured speech. This symptom reflects the heightened state of arousal and the difficulty in controlling anxious thoughts.

A. A high concentration of carbon monoxide can cause death. B. I should purchase a carbon monoxide detector for my home. C. Breathing in carbon monoxide can cause headaches and nausea. D. I can detect the presence of carbon monoxide by a metallic odor.

Correct Answer is D

Explanation

Choice A reason: A High Concentration of Carbon Monoxide Can Cause Death

This statement is correct. Carbon monoxide (CO) is a colorless, odorless, and tasteless gas that can be deadly at high concentrations. It binds to hemoglobin in the blood more effectively than oxygen, leading to hypoxia (lack of oxygen) in body tissues. High levels of CO can cause severe symptoms such as confusion, loss of consciousness, and death if not treated promptly.

Choice B reason: I Should Purchase a Carbon Monoxide Detector for My Home

This statement is also correct. Installing a carbon monoxide detector in the home is a crucial safety measure. These detectors can alert individuals to the presence of CO, allowing them to take action before the gas reaches dangerous levels. It is recommended to place detectors near sleeping areas and to test them regularly to ensure they are functioning properly.

Choice C reason: Breathing in Carbon Monoxide Can Cause Headaches and Nausea

This statement is accurate. Early symptoms of carbon monoxide poisoning include headaches, dizziness, nausea, and fatigue. These symptoms occur because CO interferes with the body’s ability to transport and use oxygen, leading to hypoxia. If exposure continues, symptoms can worsen and lead to more severe health issues.

Choice D reason: I Can Detect the Presence of Carbon Monoxide by a Metallic Odor

This statement indicates a need for further instruction. Carbon monoxide is odorless, which means it cannot be detected by smell. This is why CO is often referred to as a “silent killer.” Relying on the ability to smell CO is dangerous and ineffective. The only reliable way to detect CO is through the use of a carbon monoxide detector.

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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

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Explanation

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Correct Answer is D

Explanation

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