A nurse is caring for a patient who has just experienced a tonic-clonic seizure. Which of the following actions should the nurse perform first after ensuring the patient's safety?

Document the seizure activity in the patient's medical record.

Check the patient's vital signs

Administer oral antiepileptic medication.

Place the patient in a side-lying position.

Answer and Explanation

The Correct Answer is D

A.   Documenting the seizure activity is important but should be done after addressing immediate needs.
B.   Checking the patient's vital signs is important but is secondary to positioning the patient safely to prevent aspiration.
C.   Administering oral antiepileptic medication is necessary but not the first action following a tonic- clonic seizure.
D.   Placing the patient in a side-lying position immediately after the seizure ensures that the airway remains open and reduces the risk of aspiration.

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Correct Answer is D

Explanation

A. Klebsiella pneumoniae is a Gram-negative bacterium and is typically associated with more severe pneumonia, particularly in patients with underlying lung disease, but it does not form clusters.
B. Streptococcus pneumoniae is a common cause of pneumonia but typically appears as Gram-positive cocci in pairs or chains, not clusters.
C. Escherichia coli is a Gram-negative bacterium that generally causes urinary tract infections and is not a common cause of pneumonia with Gram-positive cocci in clusters.
D. Staphylococcus aureus is a Gram-positive bacterium that forms clusters and is a common cause of pneumonia, particularly in young, otherwise healthy individuals, and can present with fever, chills, and productive cough. This fits the presentation and sputum findings in this patient.

A. Drink fruit juices instead of whole fruits to avoid fiber. B. Eliminate all carbohydrates from the diet. C. Increase intake of high-per foods such as vegetables and whole grains. D. Consume high-protein, high-fat meals to maintain satiety.

Correct Answer is C

Explanation

A. Drinking fruit juices instead of whole fruits may increase blood sugar levels due to the lack of fiber in juices. Whole fruits are better for blood glucose control.
B. Eliminating all carbohydrates is not advisable, as carbohydrates are necessary for energy. A balanced diet with controlled carbohydrates is recommended.
C. Increasing the intake of high-fiber foods like vegetables and whole grains helps regulate blood glucose levels by slowing digestion and improving insulin sensitivity.
D. Consuming high-protein, high-fat meals could negatively affect blood sugar levels and cardiovascular health, which is a concern for diabetics.

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A nurse is caring for a patient who has just experienced a tonic-clonic seizure. Which of the following actions should the nurse perform first after ensuring the patient's safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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