A nurse is caring for a client experiencing a tonic-clonic seizure. What is the nursing priority in caring for this client?
Educating the client on anticonvulsant medications
Monitor vital signs
Restraining the client
Prevention of occlusion of airway or aspiration
The Correct Answer is D
A. Educating the client on anticonvulsant medications is important, but it is not the priority during an active seizure. Education should be provided after the seizure has ended.
B. Monitoring vital signs is important but should not be the immediate priority during a seizure. The nurse should focus on airway management first.
C. Restraining the client is contraindicated during a seizure. Restraining can cause injury to both the client and the nurse. The focus should be on protecting the client from harm.
D. The prevention of occlusion of the airway or aspiration is the priority. During a tonic-clonic seizure, there is a risk of the client choking, biting their tongue, or having difficulty breathing. The nurse should ensure the airway is open, prevent aspiration, and protect the client from injury during the seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The ECG finding of an irregularly irregular heart rate without P waves is characteristic of atrial fibrillation, which is expected in this client. This finding is not the priority in this situation.
B. Slurred speech is a potential sign of a stroke, which is a serious complication of atrial fibrillation due to the increased risk of thromboembolic events (e.g., stroke). This is the priority finding because it requires immediate intervention to assess and manage a possible stroke.
C. An aPTT of 70 seconds is slightly elevated, but it is within the therapeutic range for heparin therapy (usually 1.5 to 2.5 times the normal value). It does not warrant immediate action.
D. Cloudy and odorous urine could indicate a urinary tract infection or other issue, but it is not immediately life-threatening compared to the potential for a stroke in this client.
Correct Answer is A
Explanation
A. TIA stands for Transient Ischemic Attack, which is a temporary disruption of blood flow to the brain. Symptoms typically last for minutes to hours and resolve within 24 hours without causing permanent neurological damage.
B. CVA stands for Cerebrovascular Accident, which refers to a stroke. A CVA causes permanent neurological damage due to a lack of blood flow to the brain.
C. TPN stands for Total Parenteral Nutrition, which is a method of delivering nutrition intravenously to patients who cannot eat or absorb food normally. It is unrelated to cerebral circulation.
D. MI stands for Myocardial Infarction, which is a heart attack. It involves damage to the heart muscle due to a lack of blood flow but does not refer to cerebral circulation.
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