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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Bran muffins are a good choice for relieving constipation because they are high in dietary fiber. Fiber adds bulk to the stool and helps promote regular bowel movements. It can soften the stool, making it easier to pass.
Puffed rice cereal is a low-fiber food and may not provide significant relief for constipation. It is typically low in fiber and may not help in promoting regular bowel movements.
Tomato juice, while a healthy choice, is not particularly high in fiber. It contains some fiber, but not as much as other options like bran muffins.
Cottage cheese is a good source of protein, but it is not known for its high fiber content. While it can be a part of a balanced diet, it may not have a significant impact on relieving constipation.
Correct Answer is C
Explanation
a.Applying the restraint under the client's clothes: Restraints should be applied over the client's clothes to avoid direct skin contact and reduce the risk of skin irritation or injury.
b.Tying the restraint to the railing of the client's bed: Restraints should not be tied to bed rails or any other fixed objects. This can increase the risk of injury to the client and should be avoided.
c.Placing the client in a sitting position is appropriate when applying a belt restraint, as it helps prevent respiratory compromise and allows the client to maintain a safer and more comfortable posture.
d.A belt restraint should be placed around the client's waist, not across the chest, to avoid restricting breathing.
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