A nurse enters a client’s room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

Lift the client to the bed with assistance.

Turn the client onto their back.

Clear the nearby area of furniture.

Place a tongue depressor in the client’s mouth.

Answer and Explanation

The Correct Answer is C

Choice A Reason

Lifting the client to the bed with assistance is not recommended during a seizure. Moving the client can increase the risk of injury to both the client and the nurse. The primary focus should be on ensuring the client’s safety by preventing injury from nearby objects and allowing the seizure to run its course.

Choice B Reason

Turning the client onto their back is not advisable during a seizure. This position can increase the risk of airway obstruction and aspiration. Instead, the client should be turned onto their side to maintain an open airway and allow any secretions to drain from the mouth, reducing the risk of aspiration.

Choice C Reason

Clearing the nearby area of furniture is the most appropriate action. This helps to prevent the client from injuring themselves on hard or sharp objects during the seizure. Ensuring a safe environment is a key priority in managing a seizure, as it minimizes the risk of physical harm.

Choice D Reason

Placing a tongue depressor in the client’s mouth is an outdated and dangerous practice. It can cause injury to the client’s teeth, mouth, or airway. There is also a risk of the client biting down and breaking the depressor, leading to choking hazards. Modern seizure management guidelines strongly advise against placing any objects in the client’s mouth during a seizure.

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Correct Answer is C

Explanation

Choice A Reason: Have a fecal occult blood test every 2 years.

The recommendation for fecal occult blood tests (FOBT) is typically to have them annually, not every 2 years. Regular screening is crucial for early detection of colorectal cancer. The American Cancer Society suggests that people aged 45 and older should have an FOBT every year. This test helps detect hidden blood in the stool, which can be an early sign of cancer.

Choice B Reason: Limit intake of dietary fiber.

Dietary fiber is actually beneficial in reducing the risk of colorectal cancer. High-fiber diets, rich in fruits, vegetables, and whole grains, are associated with a lower risk of developing colorectal cancer. Fiber helps in maintaining a healthy digestive system and can aid in the prevention of cancer by promoting regular bowel movements and reducing the time that potential carcinogens stay in the colon.

Choice C Reason: Reduce intake of red meats.

Reducing the intake of red meats is a well-supported recommendation for lowering the risk of colorectal cancer. Studies have shown that high consumption of red and processed meats is linked to an increased risk of colorectal cancer. Reducing the intake of these meats and opting for healthier protein sources like fish, poultry, and plant-based proteins can help lower this risk.

Choice D Reason: Have a colonoscopy every 3 years.

The standard recommendation for colonoscopy screening is every 10 years for individuals at average risk, starting at age 45. More frequent colonoscopies, such as every 3 years, are generally reserved for those with higher risk factors, such as a family history of colorectal cancer or the presence of polyps. Regular colonoscopy screenings are vital for detecting and removing polyps before they can develop into cancer.

A. “You should be fine as long as you check your blood glucose before eating.” B. “We can discuss several scheduling options for monitoring your blood glucose.” C. “You should reorganize your schedule around your blood glucose monitoring.” D. “Your provider will set up a schedule for when you should monitor your blood glucose.”

Correct Answer is B

Explanation

The correct answer is b. “We can discuss several scheduling options for monitoring your blood glucose.”

Choice A Reason

“You should be fine as long as you check your blood glucose before eating.” This response is not ideal because it oversimplifies the complexity of managing insulin-dependent diabetes. Blood glucose monitoring should be done at various times throughout the day, including before meals, after meals, and possibly before bedtime, to ensure proper management and avoid complications. Limiting checks to just before meals may not provide a comprehensive picture of the client’s glucose levels.

Choice B Reason

“We can discuss several scheduling options for monitoring your blood glucose.” This response is the most appropriate as it acknowledges the client’s concern and offers a collaborative approach to finding a solution. It allows the nurse to tailor the blood glucose monitoring schedule to fit the client’s busy lifestyle, ensuring better adherence and management of diabetes. This approach also empowers the client by involving them in their care plan.

Choice C Reason

“You should reorganize your schedule around your blood glucose monitoring.” While it is important for the client to prioritize their health, this response may come across as dismissive of the client’s busy schedule. It does not offer practical solutions or flexibility, which are crucial for long-term adherence to diabetes management. A more supportive and collaborative approach would be more effective.

Choice D Reason

“Your provider will set up a schedule for when you should monitor your blood glucose.” This response places the responsibility solely on the healthcare provider and does not address the client’s immediate concern about fitting blood glucose monitoring into their busy schedule. While the provider’s input is important, the nurse should also offer immediate support and practical solutions. Collaborative planning is key to effective diabetes management.

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A nurse enters a client’s room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

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