A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure.
Which of the following actions should the nurse take?
- Lower the side rails of the bed when the seizure begins.
- Measure the duration of the seizure.
- Restrain the client's arms and legs to prevent injury.
Insert an oral airway into the client's mouth.
Lower the side rails of the bed when the seizure begins.
Measure the duration of the seizure.
Restrain the client's arms and legs to prevent injury.
Insert an oral airway into the client's mouth.
The Correct Answer is B
Lowering the side rails of the bed could lead to the client falling from the bed. Instead raise the side rails and place padding on them.
Measuring the seizure duration is a crucial step for medical evaluation afterwards necessary for determining intervention.
Inserting an oral airway into the client's mouth is not indicated during a tonic-clonic seizure. It is generally not recommended to place any objects or devices into the mouth of a person having a seizure, as it can potentially cause injury to the person or damage to the airway.
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Related Questions
Correct Answer is C
Explanation
A.Wearing a face mask does not increase the risk of injury. In fact, it helps protect the client from infections, especially if they have concurrent neutropenia, which is common in conditions affecting the bone marrow.
B.Green, leafy vegetables are rich in vitamin K, which plays a role in clotting. However, they do not directly increase the risk of injury in a client with thrombocytopenia. While vitamin K affects clotting factors, thrombocytopenia primarily involves a deficiency of platelets, which are necessary for clot formation.
C.Clients with thrombocytopenia have a low platelet count, which increases their risk of bleeding. Using a firm-bristled toothbrush can cause gum trauma and bleeding, leading to complications such as prolonged bleeding or infection. A soft-bristled toothbrush or an alternative oral hygiene method (such as an oral swab) is recommended to minimize injury.
D.Adequate sleep does not increase the risk of injury. In fact, it may support overall health and immune function.
Correct Answer is B
Explanation
Before any invasive procedure, it is essential to ensure that the client has given informed consent. Informed consent involves providing the client with detailed information about the procedure, its risks and benefits, and alternatives. The client should have the opportunity to ask questions and fully understand the procedure before giving consent.
Oral contrast solutions are typically used for imaging procedures such as CT scans or X-rays, not for esophagogastroduodenoscopy. This procedure involves the insertion of a flexible tube with a camera into the esophagus, stomach, and duodenum to visualize the upper gastrointestinal tract.
While it is important to provide the client with information about the duration of the procedure, stating a specific time frame may not be accurate or helpful. The duration of an esophagogastroduodenoscopy can vary depending on factors such as the complexity of the procedure and the client's individual circumstances.
Having a full bladder is not necessary for an esophagogastroduodenoscopy procedure. This requirement may be relevant for other procedures, such as pelvic ultrasound, but it is not applicable in this case.
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