A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following action should the nurse take?

Insert an oral airway into the client’s mouth

Measure the duration of the seizure.

Lower the side rails of the bed when the seizure begins.

Restrain the client's arms and legs to prevent injury.

None

Answer and Explanation

The Correct Answer is B

A. Attempting to force an object into the oral cavity during muscle contraction causes dental trauma or jaw fractures. It significantly increases the risk of aspiration if the object breaks or triggers a gag reflex. Modern clinical guidelines strictly prohibit the insertion of any device into the mouth during active convulsions. Airway patency is maintained by placing the client in a lateral position.

B. Tracking the exact duration of the ictal phase is a critical nursing responsibility for clinical assessment. This data determines the necessity for emergency benzodiazepines if the event lasts longer than 5 minutes. Precise timing helps differentiate between a self-limiting seizure and dangerous status epilepticus. The nurse must record the start and end times to guide medical intervention.

C. Lowering the side rails during a seizure increases the risk of the client falling from the height of the bed. Standard seizure precautions require that side rails remain raised and should be padded to prevent blunt force trauma. Ensuring the patient stays within the safe boundaries of the bed is a primary safety goal.

D. Physical restraints can cause severe musculoskeletal injuries such as fractures or dislocations during the forceful involuntary movements of the clonic phase. Restricting the extremities creates unnecessary resistance against powerful muscle contractions. The nurse should clear the immediate area of hard objects rather than holding the client down.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","B","C"]

Explanation

A. "I can expect my contact lenses to turn red or orange.”
Rifampin causes red-orange discoloration of body fluids, including tears, sweat, urine, and saliva. This effect is harmless but can stain soft contact lenses permanently, so clients should be advised to use glasses instead.

B. “I should notify my provider if I start taking new over-the-counter or prescription medications.”
Rifampin is a potent enzyme inducer that can alter the metabolism of many drugs, including oral contraceptives and anticoagulants. The provider should be informed of any new medications to avoid potential drug interactions and ensure therapeutic effectiveness.

C. “I will need to have someone observe me when I take my medication.”
Directly observed therapy (DOT) is recommended to ensure adherence to tuberculosis treatment. A healthcare provider or designated individual supervises medication intake to improve compliance and reduce the risk of drug resistance.

D. “I will need to have a repeat Mantoux test in 4 weeks.”
A repeat Mantoux test is unnecessary for diagnosing active tuberculosis, as this condition is confirmed through sputum cultures and chest X-ray findings. Mantoux testing is primarily used for screening latent TB infections.

E. “I am no longer contagious.”
Clients with active tuberculosis remain contagious until they complete at least two weeks of effective multidrug therapy and show clinical improvement. Until then, infection control measures such as respiratory isolation should be followed.

F. “I will need to take my medications for a total of 6 weeks.”
The standard treatment for active tuberculosis lasts at least six months, typically involving a four-drug regimen for the first two months, followed by two drugs for the remaining four months. A six-week course is insufficient for eradication.

G. "I can continue my current alcohol intake."
Alcohol should be avoided due to the hepatotoxic effects of isoniazid, rifampin, and pyrazinamide. Combining alcohol with these medications increases the risk of liver damage, requiring clients to abstain or limit intake.

A. Tell the client to leave the group if they cannot contribute. B. Allow the client extra time to think of a response. C. Appoint the client to lead the discussion. D. Ask other group members to limit the number of times they speak.

Correct Answer is B

Explanation

A) Tell the client to leave the group if they cannot contribute.
This response is inappropriate as it does not support the client’s participation or create an open, supportive environment. Forcing the client to leave would alienate them and potentially discourage future participation. Group therapy should foster inclusiveness and understanding, not create pressure or exclusion.

B) Allow the client extra time to think of a response.
This is the most appropriate action. Some clients may need additional time to process their thoughts before speaking, especially in a group setting where they may feel anxious or hesitant. Giving the client space and time to formulate a response can encourage participation without forcing them. It allows them to engage at their own pace, promoting comfort and confidence in the group.

C) Appoint the client to lead the discussion.
While giving the client an active role might help them engage, appointing them to lead the discussion could cause undue stress or anxiety, particularly if they are already struggling to contribute. This could overwhelm the client and make them feel more isolated. Instead, a gradual approach to participation is more effective.

D) Ask other group members to limit the number of times they speak.
While this may seem like an effort to allow more time for the silent client, it may not be the best solution. Group therapy is meant to be interactive, and limiting others’ participation may make the group feel less collaborative. It is better to encourage the silent client to speak at their own pace rather than restricting the group’s natural flow of discussion.

View Question and Answer

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

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Select the 3 client statements that indicate an understanding of the teaching.

Correct Answer is ["A","B","C"]

Explanation

A nurse is assisting with a group therapy session and notes a client who remains silent. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is collecting data from a newborn who has fetal alcohol syndrome. Which of the following manifestations should the nurse (Select all that apply.)

A nurse is reinforcing teaching about circumcision care with the parent of an infant who just underwent a Plastibell circumcision. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is reinforcing teaching with another nurse about how change an ostomy appliance for a client who has sigmoid colostomy. Which of the following instructions should the nurse include in the teaching?

A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN). Which of the following actions should the nurse take?

A nurse is assisting in the care of a client who presents to the emergency department A nurse is reviewing the client's medical record. Which of the following findings indicate the need for further evaluation? Select all that apply.

A nurse is assisting in the care of a client who is malnourished and states, ‘’I refuse to eat right now. It goes against my beliefs.’’ Which of the following responses should nurse make?

A nurse is reinforcing teaching with a client who has a new prescription for epinephrine auto-injector PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations?

A nurse is preparing to test a client's plantar Babinski reflex. Which of the following instructions should the nurse give to prepare the client for this test?