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

Insert a tongue blade in the client's mouth.

Restrain the client's arms and legs.

Place the client on her side.

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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Correct Answer is B

Explanation

A. Whole wheat pasta: Whole wheat products are high in insoluble fiber, which can exacerbate symptoms of irritable bowel syndrome (IBS) like bloating and cramping. Clients with IBS often tolerate soluble fiber better than insoluble fiber.

B. Strawberries: Strawberries are a low- (Fermentable Oligo-, Di-, Mono-saccharides And Polyols) FODMAP fruit and generally well tolerated in IBS. They contain soluble fiber, which can help regulate bowel movements without worsening gas or bloating, making them a suitable choice.

C. Rye toast: Rye contains high levels of fructans, a type of fermentable carbohydrate that can trigger IBS symptoms such as gas, bloating, and discomfort, especially in clients sensitive to FODMAPs.

D. Brussels sprouts: These are known to cause gas and bloating due to their high content of fermentable carbohydrates. They are often poorly tolerated by individuals with IBS and should be limited or avoided.

A. Scheduling healthy cooking classes for clients who have hypertension B. Performing environmental assessments to identify local safety issues C. Hosting early detection programs for substance use at local high schools D. Implementing influenza immunization clinics for older adults

Correct Answer is D

Explanation

A. Scheduling healthy cooking classes for clients who have hypertension:This intervention is secondary or tertiary prevention because it targets individuals who already have a chronic condition. The goal is to manage or prevent complications, not to prevent the disease.

B. Performing environmental assessments to identify local safety issues:Environmental assessments are considered part of community diagnosis and planning rather than direct primary prevention.

C. Hosting early detection programs for substance use at local high schools:This is an example of secondary prevention, as it focuses on identifying and intervening early in substance use behavior rather than preventing it from starting in the first place.

D. Implementing influenza immunization clinics for older adults:Immunizations are a classic example of primary prevention because they are designed to prevent the onset of disease before it occurs. Vaccination protects individuals from acquiring infections like influenza.

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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?

Nursing Test Bank

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