A nurse is caring for a client who has a seizure disorder.
A nurse is caring for a client who has a seizure disorder. What following actions should the nurse take? (Select all that apply.)
Time the duration of the seizure.
Administer supplemental oxygen to the client.
Place a tongue depressor in the client’s mouth.
Turn the client to the side.
Restrain the client.
Correct Answer : A,B,D
Choice A: Time the duration of the seizure
Reason: Timing the duration of a seizure is crucial for several reasons. Firstly, it helps in determining the type of seizure and its severity. Seizures lasting more than 5 minutes are considered medical emergencies and may require immediate intervention to prevent complications such as status epilepticus, which is a prolonged seizure that can cause brain damage or death. By recording the start and end times, healthcare providers can assess the effectiveness of treatments and make necessary adjustments. Additionally, this information is vital for documenting the patient’s medical history and for future reference in managing the condition.
Choice B: Administer supplemental oxygen to the client
Reason: Administering supplemental oxygen is essential during a seizure, especially when the client’s oxygen saturation levels drop below the normal range of 95-100%. In the provided scenario, the client’s oxygen saturation is 86%, which is significantly low and indicates hypoxemia. Hypoxemia can lead to further complications, including brain damage due to insufficient oxygen supply. Providing supplemental oxygen helps maintain adequate oxygen levels in the blood, ensuring that vital organs, including the brain, receive enough oxygen to function properly. This intervention is critical in preventing hypoxic injuries and promoting recovery post-seizure.
Choice C: Place a tongue depressor in the client’s mouth
Reason: Placing a tongue depressor in the client’s mouth during a seizure is not recommended and can be dangerous. This outdated practice was once believed to prevent the client from biting their tongue, but it poses significant risks. The client could bite down on the depressor, causing dental injuries or even breaking the depressor, leading to choking hazards. Modern seizure management guidelines advise against placing any objects in the mouth during a seizure. Instead, the focus should be on ensuring the client’s safety by clearing the area of any harmful objects and positioning them safely.
Choice D: Turn the client to the side
Reason: Turning the client to the side, also known as the recovery position, is a critical intervention during a seizure. This position helps maintain an open airway and reduces the risk of aspiration, which can occur if the client vomits or has excessive saliva. Aspiration can lead to serious respiratory complications, including pneumonia. By positioning the client on their side, gravity helps drain fluids from the mouth, preventing them from entering the airway9. This simple yet effective measure is a standard practice in seizure management to ensure the client’s safety and comfort.
Choice E: Restrain the client
Reason: Restraining a client during a seizure is not recommended and can be harmful. Seizures involve involuntary muscle contractions, and attempting to restrain the client can lead to injuries such as fractures, muscle tears, or dislocations. Additionally, restraint can increase the client’s agitation and stress, potentially worsening the seizure. The appropriate approach is to ensure the client’s safety by removing nearby objects that could cause injury and allowing the seizure to run its course. Gentle guidance and support should be provided without applying force.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: Using a kitchen spoon to administer the medication is not recommended. Kitchen spoons can vary in size and may not provide an accurate dose. It is important to use a proper measuring device, such as an oral syringe or a medication cup, to ensure the correct dosage.
Choice B reason: Written information about the medication is crucial for the parents or caregivers. This information should include the name of the medication, the dosage, the frequency of administration, and any special instructions. Providing written information helps ensure that the medication is administered correctly and consistently.
Choice C reason: The reason why the child is taking the medication should be clearly explained to the parents or caregivers. Understanding the purpose of the medication helps ensure compliance and allows them to monitor the child’s response to the treatment.
Choice D reason: The adverse effects of the medication should be discussed with the parents or caregivers. Knowing the potential side effects allows them to recognize and respond to any adverse reactions promptly. This information is essential for the safe administration of the medication.
Choice E reason: Stopping the medication when the child feels better is incorrect. Antibiotics should be taken for the full prescribed course, even if the child starts to feel better before the medication is finished. Stopping the medication early can lead to incomplete treatment of the infection and contribute to antibiotic resistance.
Correct Answer is A
Explanation
Choice A reason: Adopting a neutral attitude when providing care is essential for building trust with a client who is suspicious. A neutral attitude helps the nurse remain professional and non-threatening, which can make the client feel safer and more comfortable. This approach avoids overwhelming the client with excessive friendliness or personal disclosure, which might increase their suspicion.
Choice B reason: Waiting for the client to initiate interaction is not the best approach. Clients who are suspicious may not feel comfortable initiating interactions, and this could lead to a lack of communication and trust. The nurse should take the initiative to engage with the client in a calm and respectful manner.
Choice C reason: Disclosing some personal information to the client to demonstrate approachability can be counterproductive with a suspicious client. Sharing personal information might be perceived as intrusive or manipulative, which could increase the client’s distrust. Maintaining professional boundaries is crucial.
Choice D reason: Approaching the client frequently throughout the day for brief interactions might overwhelm a suspicious client. While regular interactions are important, they should be balanced and not too frequent to avoid making the client feel pressured or monitored.
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