A nurse is assisting a client to ambulate when the client begins to have a generalized seizure, identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Turn the client's head to the side
Guide the client to the floor.
Provide supplemental oxygen
Provide hygiene.
Initiate reorientation
The Correct Answer is B,A,C,D,E
A. Turn the client's head to the side: Turning the head to the side helps maintain airway patency and allows saliva or secretions to drain, reducing the risk of aspiration. This action is performed once the client is safely positioned and seizing. Airway protection is a priority during active seizure activity.
B. Guide the client to the floor: Safely guiding the client to the floor prevents injury from a fall during sudden loss of muscle control. This is the first priority when a seizure begins during ambulation. Protecting the client from trauma takes precedence over all other actions.
C. Provide supplemental oxygen: After the seizure activity subsides, oxygen may be needed to address hypoxia caused by impaired breathing during the seizure. Supplemental oxygen supports adequate tissue oxygenation during the postictal phase. This action follows airway positioning and stabilization.
D. Provide hygiene: Hygiene care is provided after the seizure once the client is stable, as incontinence or excessive secretions may have occurred. Maintaining cleanliness promotes comfort and dignity. This step is not urgent and is addressed after physiologic needs are met.
E. Initiate reorientation: Reorientation is performed last, during the postictal phase, when the client may be confused or disoriented. Calm reassurance and simple explanations help reduce anxiety and support neurologic recovery. This action is appropriate only once the client is alert and stable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Blood pressure 108/68 mm Hg: This blood pressure is slightly lower than average but generally within a safe range. Hydromorphone can cause hypotension, but this reading alone does not necessitate immediate intervention.
B. Respiratory rate 14/min: A respiratory rate of 14 breaths per minute is within the normal adult range (12–20/min), indicating that the client is not experiencing significant opioid-induced respiratory depression.
C. Urinary output 160 mL/8 hr: A urinary output of 160 mL over 8 hours is significantly below normal (expected >30 mL/hr). Oliguria can indicate opioid-induced urinary retention or other complications. The nurse should notify the provider for assessment and possible intervention.
D. Oxygen saturation 95%: An oxygen saturation of 95% is within normal limits for most adults and does not indicate hypoxemia. Continued monitoring is appropriate, but immediate notification is not required.
Correct Answer is D
Explanation
A. A client has difficulty voiding following the removal of an indwelling catheter: Difficulty voiding can be a common, expected postoperative or post-catheterization occurrence. It requires nursing interventions but does not warrant an incident report unless it results in harm or an adverse outcome.
B. A client reports nausea following the administration of morphine: Nausea is a known and common side effect of opioid medications like morphine. Monitoring and providing antiemetics are appropriate, but this event is anticipated and does not require an incident report.
C. A client who has type 2 diabetes mellitus did not eat their breakfast: Missing a meal may affect blood glucose control but is not considered a reportable incident. Nursing actions would include monitoring glucose and providing alternatives, rather than filing an incident report.
D. A client's arm is edematous at the peripheral IV site: Edema at an IV site may indicate infiltration, phlebitis, or extravasation, which are complications of intravenous therapy. Because it is a preventable or unexpected adverse event, it must be documented in an incident report to inform quality improvement and patient safety measures.
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