A nurse is caring for a client who is experiencing a generalized tonic-clonic seizure. Which of the following actions should the nurse take?
Apply restraints to the client.
Administer an IV bolus of lorazepam.
Place the client in the prone position.
Insert a tongue blade into the client's mouth.
The Correct Answer is B
Choice A reason: Applying restraints to the client is not an appropriate action, as it can cause injury or suffocation to the client during a seizure. The nurse should protect the client from harm by removing any nearby objects and padding the side rails.
Choice B reason: Administering an IV bolus of lorazepam is an appropriate action, as lorazepam is an anticonvulsant drug that can stop or shorten the duration of a seizure by enhancing the inhibitory effects of gamma-aminobutyric acid (GABA) in the brain.
Choice C reason: Placing the client in the prone position is not an appropriate action, as it can obstruct the airway and cause respiratory distress or aspiration during a seizure. The nurse should place the client in the side-lying position to facilitate drainage of oral secretions and prevent tongue biting.
Choice D reason: Inserting a tongue blade into the client's mouth is not an appropriate action, as it can cause oral trauma or choking during a seizure. The nurse should never force anything into the client's mouth during a seizure and should allow them to breathe spontaneously.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice c: Confusion is a finding that the nurse should anticipate in an older adult client who has cystitis, which is inflammation of the bladder caused by a bacterial infection. Confusion can be a sign of sepsis or delirium, which are common complications of urinary tract infections in older adults.
Choice a is not correct because hypothermia is not a finding that the nurse should anticipate in an older adult client who has cystitis. Hypothermia can occur in older adults due to impaired thermoregulation, but it is not related to cystitis.
Choice b is not correct because referred pain in the right shoulder is not a finding that the nurse should anticipate in an older adult client who has cystitis. Referred pain in the right shoulder can indicate gallbladder disease, but it is not related to cystitis.
Choice d is not correct because orange-colored urine is not a finding that the nurse should anticipate in an older adult client who has cystitis. Orange-colored urine can be caused by certain medications, foods, or dehydration, but it is not related to cystitis.
Correct Answer is C
Explanation
Choice A: This is incorrect because sore throat is not a finding that the nurse should report to the provider. Sore throat is a common and expected complication of bronchoscopy due to irritation from the endoscope. The nurse should provide oral care and offer ice chips or lozenges to soothe the throat.
Choice B: This is incorrect because blood pressure 110/78 mm Hg is not a finding that the nurse should report to the provider. Blood pressure 110/78 mm Hg is within the normal range and does not indicate any adverse effects from bronchoscopy. The nurse should monitor the vital signs and oxygen saturation of the client.
Choice C: This is correct because facial edema is a finding that the nurse should report to the provider. Facial edema can indicate an allergic reaction, airway obstruction, or mediastinal emphysema, which are serious and potentially life-threatening complications of bronchoscopy. The nurse should assess the airway, breathing, and circulation of the client and administer oxygen and medications as prescribed.
Choice D: This is incorrect because presence of gag reflex is not a finding that the nurse should report to the provider. Presence of gag reflex is an expected outcome of bronchoscopy, indicating that the anesthesia has worn off and the client can resume oral intake. The nurse should check the gag reflex before offering any food or fluids to the client.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today