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A nurse is caring for a client who is experiencing a seizure while in bed. Which of the following actions should the nurse take?

A.

Insert a tongue blade in the client's mouth.

B.

Restrain the client's arms and legs.

C.

Place the client on her side.

D.

Raise the client's bed to the high position.

Answer and Explanation

The Correct Answer is C

A. Insert a tongue blade in the client's mouth: Forcing any object into a client’s mouth during a seizure is dangerous and can cause oral trauma or airway obstruction. It is not recommended and can worsen the situation.

B. Restrain the client's arms and legs: Restraining a client during a seizure can lead to musculoskeletal injuries. Instead, the nurse should allow spontaneous movement and focus on protecting the client from harm.

C. Place the client on her side: Turning the client to the side helps maintain a patent airway and allows saliva or vomit to drain, reducing the risk of aspiration. It is a priority action during seizure management.

D. Raise the client's bed to the high position: Raising the bed increases the risk of injury from falls or uncoordinated movements during or after the seizure. The bed should be in a low position with padded side rails if necessary.


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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Potential Nursing Action

Anticipated

Contraindicated

Encourage the client to talk.

✔

Notify the rapid response team.

✔

Assist client to high-Fowler's position.

✔

Place emergency tracheostomy equipment in the client's room.

✔

Rationale:

  • Encourage the client to talk: Talking can strain the airway and worsen laryngeal edema or stridor. Airway obstruction is developing, and preserving respiratory function is critical. Silence reduces laryngeal movement and decreases airway irritation.
  • Notify the rapid response team: The client is showing signs of acute airway compromise: stridor, dysphagia, increasing temperature, and tachycardia. Immediate medical intervention is required to maintain oxygenation and prevent respiratory failure.
  • Assist client to high-Fowler's position: Sitting the client upright improves lung expansion and reduces pressure on the neck. This position facilitates breathing and airway patency, especially important during potential obstruction or edema.
  • Place emergency tracheostomy equipment in the client's room: Due to the risk of airway obstruction from laryngeal edema post-thyroidectomy, emergency airway access may be needed. Having tracheostomy equipment ready ensures rapid response if intubation becomes impossible.

Correct Answer is B

Explanation

A. Have the client drink 360 mL (12 oz) of plain water: While rehydration is important, plain water alone may not be sufficient to replace lost electrolytes in heat exhaustion. Oral rehydration with electrolyte-containing fluids is usually preferred.

B. Place the client in a cool environment: Moving the client to a shaded or air-conditioned environment is essential to reduce core body temperature and prevent progression to heat stroke. This is a priority action in treating heat exhaustion.

C. Immerse the client in ice water: Ice water immersion is used in severe heat stroke, not heat exhaustion. It may cause vasoconstriction and shivering, which can worsen the condition if used prematurely.

D. Give the client salt tablets: Salt tablets are not recommended due to the risk of gastrointestinal irritation and potential for sodium overload. Balanced electrolyte fluids are a safer and more effective way to restore electrolyte balance.

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