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.

Answer and Explanation

The Correct Answer is D

A. Insert an oral airway into the client’s mouth: Attempting to insert any object into the mouth during a seizure risks airway obstruction, dental injury, or aspiration of oral secretions or broken teeth. The jaw is typically clenched, making insertion unsafe and impractical.

B. Measure the duration of the seizure: While timing the seizure is important for documentation and determining if status epilepticus occurs, it should not take precedence over immediate physical safety measures. Restraint to prevent injury must occur first.

C. Lower the side rails of the bed when the seizure begins: Lowering the side rails increases the risk of the client falling from the bed. Instead, the bed rails should remain raised and padded (if possible) to create a contained, safe environment.

D. Restrain the client's arms and legs to prevent injury: Gentle but firm restraint of the extremities reduces the risk of the client striking themselves against hard surfaces (e.g., bed rails, walls) or experiencing dislocations, fractures, or self-inflicted trauma. Restraint should be applied cautiously to avoid excessive force, but it is necessary to maintain physical control during the seizure’s intense muscular contractions.

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Correct Answer is D

Explanation

A) "What makes you believe that the science behind immunization is wrong?": This question may come across as confrontational and judgmental, which can potentially shut down communication. It could make the client feel defensive and less likely to engage in an open discussion about their concerns. The nurse should aim to create a non-judgmental and open dialogue to understand the client's perspective.

B) "Is not taking the immunization worth the risk of getting very sick during flu season?": This question is somewhat leading and may sound as if the nurse is trying to pressure the client into changing their mind. It could also create a sense of guilt or fear rather than fostering a cooperative conversation about the client's beliefs and concerns.

C) "Why are you opposed to receiving immunization?": While this question may seem straightforward, it is a bit too direct and could feel accusatory to the client. It might be better to approach the conversation in a way that invites the client to express their concerns without feeling challenged or defensive.

D) "What is your biggest concern with receiving immunization?": This is the most effective and open-ended question. It allows the client to express their concerns in a non-confrontational way. The nurse can then listen to the client's reasons, provide information, and address any misconceptions or fears the client may have, fostering a respectful and informative discussion.

A. Believes the death is punishment for bad behavior B. Recognizes the parent will never wake up C. Understands that everyone dies eventually D. Expresses curiosity about the funeral service

Correct Answer is A

Explanation

A) Believes the death is punishment for bad behavior: Preschoolers, typically ages 3 to 5, often engage in magical thinking and may believe that death is a result of their own actions or bad behavior. They may see death as a punishment for something they did wrong, as they have difficulty understanding the permanence and inevitability of death. This egocentric thinking is typical for their developmental stage.

B) Recognizes the parent will never wake up: Preschoolers may not yet fully comprehend the permanence of death. They may think the deceased parent will eventually wake up or return. This belief reflects their limited understanding of death, which they may view as reversible or temporary, especially if they haven't encountered death before.

C) Understands that everyone dies eventually: Preschoolers do not generally have the cognitive ability to grasp the concept that everyone dies eventually. This understanding develops later, typically during the concrete operational stage of development (around age 7 or 8), when children begin to understand death as permanent and universal.

D) Expresses curiosity about the funeral service: While some preschoolers may express curiosity about events like a funeral, it is more likely that their curiosity would be centered on simple, tangible aspects of death (such as asking questions about where the person went or what happens to their body) rather than the ceremony itself. At this stage, children may not fully understand the cultural or symbolic meanings of a funeral service.

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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

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Explanation

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Correct Answer is A

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