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 B
Explanation
Choice A reason: The thigh-high stockings should reach just below the gluteal folds, not above them. If the stockings are too high, they can cause constriction and impair circulation.
Choice B reason: Reapplying the stockings before getting out of bed is an appropriate action. The client should remove the stockings at night and inspect the skin for any signs of irritation or breakdown. The client should also elevate the legs for 15 minutes before putting on the stockings to reduce edema and improve venous return.
Choice C reason: Flexing the toes when applying the stockings is not an appropriate action. The client should point the toes and foot downward when applying the stockings to prevent wrinkles or folds that can cause pressure ulcers.
Choice D reason: Rolling down knee-high stockings slightly to provide comfort is not an appropriate action. The client should avoid rolling or folding the stockings as this can create a tourniquet effect and impair blood flow.
Correct Answer is D
Explanation
Choice A: This is incorrect. The client having difficulty reading large print indicates a need for an ophthalmology referral, not an occupational therapy referral. An ophthalmologist can assess and treat vision problems caused by stroke.
Choice B: This is incorrect. The client coughing while drinking from a straw indicates a need for a speech therapy referral, not an occupational therapy referral. A speech therapist can assess and treat swallowing problems caused by stroke.
Choice C: This is incorrect. The client being unable to bear her full weight while walking indicates a need for a physical therapy referral, not an occupational therapy referral. A physical therapist can assess and treat mobility problems caused by stroke.
Choice D: This is correct. The client becoming exhausted while brushing her teeth indicates a need for an occupational therapy referral. An occupational therapist can assess and treat functional problems caused by stroke, such as fatigue, self-care, cognition, and leisure activities.
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