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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is a false statement, because adults do not receive a natural immunity to herpes zoster from casual exposure to children who have had chickenpox. Herpes zoster is caused by the reactivation of the varicella-zoster virus, which remains dormant in the nerve cells after a primary infection with chickenpox.
Choice B reason: This is a false statement, because herpes zoster is not prevented by the MMR vaccine, which protects against measles, mumps, and rubella. Herpes zoster is prevented by the varicella vaccine, which is given separately from the MMR vaccine.
Choice C reason: This is a false statement, because a client who has herpes zoster is contagious if blisters are present on the skin. The blisters contain the varicella-zoster virus, which can be transmitted through direct contact or airborne droplets.
Choice D reason: This is the correct statement, because herpes zoster is contagious to people who have never had chickenpox. People who have never had chickenpox can contract the varicella-zoster virus from a person who has herpes zoster and develop chickenpox as a primary infection.
Correct Answer is C
Explanation
Choice A reason: This is an incorrect instruction, because the client does not need to remain NPO, or nothing by mouth, before a standard EEG. The client can eat and drink normally, unless the provider instructs otherwise.
Choice B reason: This is an incorrect instruction, because the client should not take a sedative, or any other medication that can affect the brain activity, before a standard EEG. The client should take the usual medications, unless the provider instructs otherwise.
Choice C reason: This is the correct instruction, because the client should thoroughly shampoo hair prior to the EEG. The client should wash the hair with a mild shampoo and rinse well, without using any conditioner, gel, spray, or other hair products. This can help remove any oil, dirt, or residue that can interfere with the placement and function of the electrodes.
Choice D reason: This is an incorrect instruction, because the client should not take an additional dose of anticonvulsant medication before a standard EEG. The client should take the regular dose of anticonvulsant medication, unless the provider instructs otherwise.
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