A nurse finds a client on the floor of their room experiencing a seizure. Which of the following actions is the nurse's priority?

Place the client on their side with their head forward.

Administer an anticonvulsant medication.

Time the length of the client's seizure.

Loosen the client's gown and allow them to move freely.

Answer and Explanation

The Correct Answer is A

A. Place the client on their side with their head forward. This position helps maintain an open airway, prevents aspiration, and allows secretions to drain. It is the priority intervention during an active seizure.

B. Administer an anticonvulsant medication. Medications like benzodiazepines (e.g., lorazepam) are used to stop prolonged seizures but are not the immediate priority over airway protection.

C. Time the length of the client's seizure. While monitoring seizure duration is important, ensuring airway protection and safety comes first.

D. Loosen the client's gown and allow them to move freely. While restrictive clothing should be loosened, allowing unrestricted movement could lead to self-injury.

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Correct Answer is B

Explanation

A. Decreased blood urea nitrogen (BUN): BUN typically increases with dehydration.

B. Increased hematocrit: Hemoconcentration occurs in dehydration, increasing hematocrit levels.

C. Decreased urine specific gravity: Dehydration typically causes an increase in urine specific gravity.

D. Increased calcium level: Calcium levels do not directly indicate fluid volume status.

A. "I can exercise as late as 1 hour before bedtime." B. "I should reduce my fluid intake 2 hours before bedtime." C. "I should take a 1 hour nap each day. D. "I can eat a large meal as late as 1 hour before bedtime."

Correct Answer is B

Explanation

A. "I can exercise as late as 1 hour before bedtime." Exercise close to bedtime can increase alertness and make it harder to fall asleep. It is recommended to finish exercising at least 3-4 hours before bedtime.

B. "I should reduce my fluid intake 2 hours before bedtime." Reducing fluid intake before bedtime helps minimize nocturia, which can disrupt sleep.

C. "I should take a 1-hour nap each day." Long or frequent naps can interfere with nighttime sleep. If naps are needed, they should be limited to 20-30 minutes earlier in the day.

D. "I can eat a large meal as late as 1 hour before bedtime." Eating a heavy meal before bed can cause discomfort and acid reflux, which may disrupt sleep. A light snack is preferable.

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A nurse finds a client on the floor of their room experiencing a seizure. Which of the following actions is the nurse's priority?

Nursing Test Bank

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