A nurse is caring for a client in bed and begins experiencing a tonic-clonic seizure.
Which of the following actions should the nurse take?
Insert an oral airway into the client's mouth.
Lower the side rails of the bed when the seizure begins.
Measure the duration of the seizure.
Restrain the client's arms and legs to prevent injury.
The Correct Answer is C
A. Insert an oral airway into the client's mouth. Inserting anything into the client’s mouth during a seizure is contraindicated due to the risk of oral injury, aspiration, or causing airway obstruction.
B. Lower the side rails of the bed when the seizure begins. Lowering the side rails is inappropriate and increases the risk of the client falling out of bed and sustaining an injury. Instead, the nurse should ensure padded side rails are in place or protect the client by cushioning their head and limbs if side rails are not padded.
C. Measure the duration of the seizure. It is critical to measure the duration of a seizure to provide accurate information to the healthcare team. The duration helps determine the severity of the seizure and the need for medical interventions, such as administering medications to stop prolonged seizures (status epilepticus).
D. Restrain the client's arms and legs to prevent injury. Restraint during a seizure is inappropriate and can cause musculoskeletal injuries. The nurse should allow the seizure to run its course while ensuring the client’s safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Creating a schedule of daily tasks can help provide structure and routine for individuals with Alzheimer's disease. Having a predictable routine can reduce confusion and frustration by providing a sense of familiarity and stability. The schedule should include activities that the client enjoys and can manage within their abilities. It can help the client feel more organized and engaged throughout the day.
Limiting the use of familiar objects is not recommended. Familiar objects can provide comfort and a sense of security for individuals with Alzheimer's disease. They can help trigger memories and create a sense of familiarity in their environment. Removing familiar objects may increase disorientation and frustration.
Asking questions that require more than one answer can be overwhelming for individuals with Alzheimer's disease. Complex questions can lead to confusion and frustration as the person may struggle to recall or process information. It is best to ask simple and direct questions that can be easily understood and answered.
Having several family members visit daily may cause additional stress and confusion for the client with Alzheimer's disease. Too many visitors can be overwhelming and may disrupt the person's routine or environment. It is important to consider the individual's preferences and abilities when planning visits and ensure that they are manageable and supportive for the client's well-being.
Correct Answer is ["B","D"]
Explanation
The correct answer is Choices B and D.
Choice A rationale: Using confrontation to manage a client’s behavior is not recommended, especially for clients with Alzheimer’s disease. Confrontation can lead to increased agitation, confusion, and distress in these clients. It’s important to approach clients with Alzheimer’s disease in a calm, reassuring manner and to validate their feelings and experiences.
Choice B rationale: Limiting the number of choices for the client is a beneficial strategy when caring for clients with Alzheimer’s disease. Too many choices can overwhelm these clients and lead to increased confusion and frustration. By simplifying decisions, caregivers can help to reduce the client’s stress and improve their ability to function.
Choice C rationale: While it’s important to keep clients with Alzheimer’s disease engaged and stimulated, providing a stimulating environment can be counterproductive. Too much stimulation can overwhelm these clients and lead to increased confusion and agitation. It’s more beneficial to provide a calm, quiet, and familiar environment for these clients.
Choice D rationale: Using written signs to assist the client with locating the bathroom can be very helpful for clients with Alzheimer’s disease. As the disease progresses, these clients often struggle with memory loss and disorientation. Clear, simple signs can help them navigate their environment and maintain a level of independence.
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