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.

Answer and Explanation

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.

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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.

A. Administer aspirin if the client develops a fever. B. Initiate contact precautions for the client. C. Assign the client to a negative-pressure airflow room. D. Have visitors remain at least 0.91 m (3 feet. away from the client.

Correct Answer is C

Explanation

The correct answer is choicec. Assign the client to a negative-pressure airflow room.

Choice A rationale:

Administering aspirin to a client with varicella zoster is not recommended due to the risk of Reye’s syndrome, a serious condition that can cause swelling in the liver and brain.

Choice B rationale:

While contact precautions are important, varicella zoster also requires airborne precautions due to its highly contagious nature. This means that simply initiating contact precautions is not sufficient.

Choice C rationale:

Assigning the client to a negative-pressure airflow room is crucial because it helps contain the airborne virus and prevents it from spreading to other areas of the hospital.

Choice D rationale:

Having visitors remain at least 0.91 m (3 feet) away from the client is a good practice, but it is not sufficient on its own to prevent the spread of the virus. Airborne precautions, including a negative-pressure room, are necessary.

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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?

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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?