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 D

Explanation

A. “I'm sure your situation will get better with time." This response is dismissive and does not acknowledge the client’s feelings. It provides false reassurance rather than support.

B. "It must be terrible to be in this situation." While this statement attempts empathy, it may sound judgmental or patronizing rather than encouraging meaningful discussion.

C. "If I were you, I would talk with the hospital chaplain." This response assumes what the client should do rather than exploring their current coping mechanisms. It does not encourage self-reflection.

D. “Tell me what you have done in the past to cope with your problems.” This response uses therapeutic communication by allowing the client to reflect on past coping strategies and explore potential solutions.

A. “The body produces antibodies in response to an antigen with active immunity." B. "There is lifelong immunity with passive immunity." C. "The body is able to recognize previous exposure to antigens with passive immunity." D. "There is a short duration of immunity with active immunity."

Correct Answer is A

Explanation

A. "The body produces antibodies in response to an antigen with active immunity." Active immunity develops after exposure to an antigen, leading to antibody production.

B. "There is lifelong immunity with passive immunity." Passive immunity is temporary (e.g., maternal antibodies).

C. "The body is able to recognize previous exposure to antigens with passive immunity." Passive immunity does not create immune memory.

D. "There is a short duration of immunity with active immunity." Active immunity is long-lasting and sometimes lifelong.

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