A nurse is caring for a client following a seizure. Which of the following actions should the nurse take?

Apply restraints if the client is agitated.

Ambulate the client.

Position the client on their side.

Raise all of the side rails on the client's bed.

Answer and Explanation

The Correct Answer is C

A. Apply restraints if the client is agitated. Restraints are not necessary and may increase distress. Post-seizure agitation should be managed with reassurance and monitoring.
B. Ambulate the client. This is unsafe because the client may be disoriented or weak, increasing the risk of falls. Rest and recovery should be prioritized.
C. Position the client on their side. This helps maintain an open airway, prevents aspiration, and facilitates secretion drainage, making it the priority intervention.
D. Raise all of the side rails on the client's bed. Raising all four side rails is considered a restraint. A safer environment should be maintained without unnecessary restriction.

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Correct Answer is C

Explanation

A. The client has been in the restraints for 4 hr. This is incorrect because the duration of restraint use is determined by the client's behavior and safety, not a set time frame. Restraints should be discontinued as soon as they are no longer necessary.
B. The client can explain the reasons for their behavior. This is incorrect because insight into behavior does not necessarily indicate that the client is no longer a danger to themselves or others.
C. The client is able to calmly follow commands. This is correct because the primary indication for removing restraints is when the client demonstrates self-control and the ability to follow directions, reducing the risk of harm.
D. The client reports that the restraints are too tight. This is incorrect because a complaint of tight restraints indicates a need for reassessment and possible adjustment, but not necessarily discontinuation.

A. "Why do you think that alternative therapies are a better choice?" B. "You should consult with your family before seeking other treatments." C. "What has your doctor told you about your treatment options?" D. "I will come back to talk to you about your decision when you feel better."

Correct Answer is C

Explanation

A. Asking "Why do you think that alternative therapies are a better choice?" may come across as judgmental or challenging the client’s decision rather than supporting it. This is not therapeutic.
B. "You should consult with your family before seeking other treatments." assumes that the client’s decision depends on their family, which disregards autonomy.
C. "What has your doctor told you about your treatment options?" is an open-ended question that allows the client to express concerns while ensuring they have the necessary information to make an informed decision. This is the best response.
D. "I will come back to talk to you about your decision when you feel better." invalidates the client’s feelings and delays an important discussion.

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A nurse is caring for a client following a seizure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Explanation

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