A nurse is caring for a client who begins to exhibit seizure activity while in bed. Which of the following actions should the nurse implement to care for the client?
Observe the time of onset and end of seizure activity.
Remove objects within reach of the client's arms and legs.
Loosen any restrictive clothing around the neck.
Place a padded tongue blade in the client's mouth
The Correct Answer is B
Choice A reason: Observing the time of onset and end of seizure activity is important, but it is not the priority action. The nurse should first ensure the safety of the client and prevent injury.
Choice B reason: Removing objects within reach of the client's arms and legs is the correct action, as it prevents the client from hitting or injuring themselves during the seizure. The nurse should also lower the bed and raise the side rails.
Choice C reason: Loosening any restrictive clothing around the neck is a good practice, but it is not as urgent as removing objects. The nurse can do this after ensuring the client's safety.
Choice D reason: Placing a padded tongue blade in the client's mouth is a wrong and dangerous action, as it can cause choking, aspiration, or damage to the teeth and oral mucosa. The nurse should never force anything into the client's mouth during a seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Notifying the health care provider of the patient's status is an important action, but not the first priority. The nurse should first assess the patient for any possible triggers of the autonomic dysreflexia, which is a life-threatening condition that occurs in patients with spinal cord injury above the level of T6. It is characterized by a sudden and severe increase in blood pressure, flushing, sweating, headache, and blurred vision.
Choice B reason: Assessing patient for tight clothing around the waist or a full bladder is the first priority action. These are common triggers of autonomic dysreflexia, which cause irritation or stimulation of the nerves below the level of injury. The nurse should remove any tight clothing, catheterize the patient if needed, or perform a bowel evacuation to relieve the pressure and prevent further complications.
Choice C reason: Reviewing the medication administration record for an antihypertensive order is a secondary action, after identifying and removing the trigger of autonomic dysreflexia. The nurse should administer the prescribed antihypertensive medication, such as nifedipine or nitroglycerin, to lower the blood pressure and prevent stroke, seizure, or cardiac arrest.
Choice D reason: Initiating oxygen via a nasal cannula and elevating patient's legs is not an appropriate action for a patient with autonomic dysreflexia. Oxygen therapy is not indicated for this condition, unless the patient has hypoxia or respiratory distress. Elevating the patient's legs can worsen the blood pressure by increasing the venous return and the cardiac output. The nurse should keep the patient in a sitting position to promote the blood flow to the lower extremities and reduce the blood pressure.
Correct Answer is A
Explanation
Choice A reason:Swaying during a Romberg test indicates a positive result, suggesting proprioceptive deficits or sensory ataxia.
Choice B reason:Unequal pupil response to light relates to cranial nerve function, not balance assessed by the Romberg test.
Choice C reason: This is incorrect. Patient taking two attempts to touch their nose while their eyes are closed is a mild impairment of coordination, which may be due to neurologic changes or other factors such as fatigue or medication. This is not a significant finding that requires immediate attention.
Choice D reason: This is incorrect. Patient complaining of mild dizziness is a common symptom of neurologic changes or vestibular dysfunction. It is not a serious finding that requires immediate attention. The nurse should monitor the patient and provide comfort measures.
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