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. Feeling pulsations in the neck is not an expected sensation during electroconvulsive therapy (ECT). The client is under general anesthesia and does not feel the procedure.
B. The client typically wakes up within 5 to 10 minutes after ECT, though they may remain drowsy for a while. 30 minutes is too long for initial awakening.
C. Post-procedure confusion and memory loss are common and temporary side effects of ECT, lasting a few hours to days in some cases.
D. Voice changes are not associated with ECT. The procedure does not affect the vocal cords or speech.

A. A client who has heart failure and received furosemide IV 8 hr ago B. A client who was admitted 24 hr ago with chest pain C. A client who had a seizure 48 hr ago and is on seizure precautions D. A client who is scheduled to have a colonoscopy in 12 hr

Correct Answer is D

Explanation

A. A client who has heart failure and received furosemide IV 8 hr ago:
Clients with heart failure require ongoing monitoring for fluid balance, electrolyte levels, and signs of worsening symptoms. IV furosemide indicates active treatment, so this client is not stable for discharge.

B. A client who was admitted 24 hr ago with chest pain:
A client with recent chest pain requires further evaluation for acute coronary syndrome (ACS). Even if pain has resolved, monitoring for cardiac events is essential. This client is not stable for discharge.

C. A client who had a seizure 48 hr ago and is on seizure precautions:
Recent seizures require continued monitoring to assess for recurrence, medication adjustments, and safety precautions. This client is not stable for discharge.

D. A client who is scheduled to have a colonoscopy in 12 hr:
A colonoscopy is an elective procedure and does not require hospitalization. This client is stable and can be discharged to free up resources for mass casualty victims.

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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

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