A nurse is caring for a client who is having a seizure. Which of the following actions should the nurse take to prevent client injury?
Place the client in a prone position.
Insert a padded tongue blade into the client's mouth.
Loosen the client's restrictive clothing.
Restrict the movement of the client's extremities.
The Correct Answer is C
Choice A reason: Placing the client in a prone position is unsafe during a seizure. The prone position can obstruct the airway and increase the risk of aspiration. The client should be placed on their side to maintain airway patency.
Choice B reason: Inserting any object, including a padded tongue blade, into the client’s mouth during a seizure is contraindicated. This can cause oral trauma, broken teeth, or airway obstruction.
Choice C reason: Loosening restrictive clothing helps prevent injury and promotes adequate ventilation during a seizure. It reduces the risk of airway compromise and allows the client to move freely without restriction. This is the correct intervention.
Choice D reason: Restricting extremity movement during a seizure can cause musculoskeletal injury. The nurse should allow the seizure to occur naturally while ensuring the environment is safe and the client is protected from harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Reporting suspected abuse to Adult Protective Services is the nurse’s legal and ethical responsibility. Visible contusions on all extremities raise concern for physical abuse, and mandatory reporting laws require healthcare providers to notify protective services to ensure client safety. This is the correct action.
Choice B reason: Interviewing the client with the adult child present is inappropriate because it may prevent the client from speaking honestly about the situation. The presence of a potential abuser can inhibit disclosure and compromise assessment accuracy.
Choice C reason: Telling the client they must answer every Question is coercive and violates patient autonomy. Clients have the right to refuse to answer questions, and forcing responses is non-therapeutic.
Choice D reason: Advising the client to consult a social worker is supportive but insufficient. While social workers provide resources and counseling, the priority action is mandatory reporting to ensure immediate safety.
Correct Answer is C
Explanation
Choice A reason: Magnesium is a naturally occurring mineral in water and is not typically associated with toxicity in household water supplies. While excessive magnesium can cause gastrointestinal upset, it is not considered a primary hazard in older homes. Testing for magnesium is not a standard safety recommendation.
Choice B reason: Potassium is also a naturally occurring mineral and is not a common contaminant of concern in household water. Potassium levels in water are generally safe and do not pose a significant health risk. Therefore, routine testing for potassium is unnecessary in the context of home hazard assessments.
Choice C reason: Lead is the correct answer because older homes often have plumbing systems that contain lead pipes, solder, or fixtures. Lead can leach into drinking water, especially if the water is acidic or has low mineral content. Chronic exposure to lead causes neurotoxicity, developmental delays in children, hypertension, and kidney damage. Testing for lead is a critical safety measure in older homes to prevent long-term health complications.
Choice D reason: Copper can leach into water from plumbing, but copper toxicity is rare and usually requires very high levels. While copper can cause gastrointestinal upset and liver damage in extreme cases, it is not the primary hazard associated with older homes. Lead remains the most significant concern.
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