A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?

Provide oxygen.

Turn the client onto his side.

Provide privacy.

Lower the client to the floor.

Answer and Explanation

The Correct Answer is D

Choice A reason: This is an important action, but not the first one. The nurse should provide oxygen after lowering the client to the floor and protecting the head, to improve the oxygenation and prevent hypoxia.

Choice B reason: This is an important action, but not the first one. The nurse should turn the client onto his side after lowering the client to the floor and protecting the head, to prevent aspiration and maintain a patent airway.

Choice C reason: This is a helpful action, but not the first one. The nurse should provide privacy after lowering the client to the floor and protecting the head, to respect the client's dignity and reduce the stimulation.

Choice D reason: This is the first action, because lowering the client to the floor and protecting the head can prevent injury and trauma to the client during the seizure. The nurse should use a pillow, blanket, or towel to cushion the head, and move any furniture or objects away from the client.

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Correct Answer is B

Explanation

Choice A reason: Maintaining the client's head of the bed at 20% is an incorrect action, because the head of the bed should be elevated at least 30% to prevent aspiration of the feeding.

Choice B reason: Monitoring the client’s blood glucose level is a correct action, because enteral feedings can affect the blood glucose level and the client may need insulin adjustments.

Choice C reason: Flushing the enteral feeding tube with 10 mL of cool water after each medication is an incorrect action, because cool water can cause cramping and nausea. The nurse should use warm water to flush the tube and use at least 30 mL of water to prevent clogging.

Choice D reason: Obtaining an x-ray after beginning the feeding is an incorrect action, because an x-ray should be obtained before starting the feeding to confirm the placement of the tube.

A. Elevated blood pressure B. Involuntary muscle spasms C. Cold intolerance D. Weight loss

Correct Answer is B

Explanation

Choice A reason: This is an incorrect finding, because elevated blood pressure is not a sign of hypoparathyroidism, which is a condition that occurs when the parathyroid glands produce insufficient parathyroid hormone (PTH). PTH regulates the calcium and phosphorus levels in the blood and bones. Elevated blood pressure can be a sign of hyperparathyroidism, which is the opposite condition.

Choice B reason: This is the correct finding, because involuntary muscle spasms are a sign of hypoparathyroidism, which causes hypocalcemia, or low blood calcium levels. Hypocalcemia can cause neuromuscular irritability and tetany, which are manifested by muscle spasms, twitching, cramps, or seizures.

Choice C reason: This is an incorrect finding, because cold intolerance is not a sign of hypoparathyroidism, but a sign of hypothyroidism, which is a condition that occurs when the thyroid gland produces insufficient thyroid hormone. Thyroid hormone regulates the metabolism and body temperature. Cold intolerance can also be a sign of Hashimoto's thyroiditis, which is an autoimmune disease that causes inflammation and destruction of the thyroid gland.

Choice D reason: This is an incorrect finding, because weight loss is not a sign of hypoparathyroidism, but a sign of hyperthyroidism, which is a condition that occurs when the thyroid gland produces excessive thyroid hormone. Thyroid hormone increases the metabolism and energy expenditure. Weight loss can also be a sign of Graves' disease, which is an autoimmune disease that causes overstimulation and enlargement of the thyroid gland.

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A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Explanation

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