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 A reason: WBC count 10,000/mm³ is within the normal range of 4,500 to 11,000/mm³ and does not indicate any infection or inflammation.
Choice B reason: BUN 20 mg/dL is within the normal range of 10 to 20 mg/dL and does not indicate any renal impairment or dehydration.
Choice C reason: Creatinine 2.3 mg/dL is above the normal range of 0.6 to 1.2 mg/dL and indicates renal dysfunction or damage, which can be caused by blood loss, hypotension, or nephrotoxic drugs during surgery. The nurse should report this value to the provider and monitor the client for signs of acute kidney injury, such as oliguria, edema, or electrolyte imbalances.
Choice D reason: Hematocrit 41% is within the normal range of 37% to 47% for females and does not indicate any anemia or polycythemia.
Correct Answer is A
Explanation
Choice A reason: Changed mental status, such as confusion, agitation, or delirium, can be a sign of a bladder infection in older adults, as they may not have the typical symptoms of dysuria, frequency, or urgency.
Choice B reason: WBC count 9,000/mm³ is within the normal range of 4,500 to 11,000/mm³ and does not indicate an infection.
Choice C reason: Diminished reflexes are not related to a bladder infection and may be due to aging, neurological disorders, or medication side effects.
Choice D reason: Temperature 37.3°C (99.1°F) is slightly elevated but not indicative of a bladder infection. Older adults may have lower baseline temperatures and may not develop fever in response to an infection.
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