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A nurse is caring for a patient who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

A.

Place a pillow under the patient's head.

B.

Loosen restrictive clothing.

C.

Clear the area of hazards.

D.

Position the patient in a side-lying position.

Answer and Explanation

The Correct Answer is D

A. Placing a pillow under the patient's head is inappropriate because it may obstruct the airway and does not prevent aspiration.

B. Loosening restrictive clothing can be helpful but is not the priority over airway protection.

C. Clearing the area of hazards is important to prevent injury, but airway protection takes precedence.

D. Positioning the patient in a side-lying position is the priority to maintain airway patency and reduce the risk of aspiration in case of vomiting.


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Related Questions

Correct Answer is B

Explanation

A. High glucose levels cause the body to use proteins for energy, causing lactic acidosis – While hyperglycemia can lead to ketosis, it does not directly cause lactic acidosis.

B. Chronic elevated blood glucose levels damage cells and cause long-term chronic organ dysfunction – Hyperglycemia leads to complications such as neuropathy, nephropathy, and retinopathy, making glucose control essential.

C. Early identification of hypoglycemia is easier to treat resulting in better outcomes – While important, the primary reason for frequent monitoring is to prevent long-term complications.

D. Carbohydrates are constantly being converted to glucose and utilized for extra energy stores – This statement is not specific to diabetes management.

Correct Answer is B

Explanation

A. Labeling the mother as "overprotective" is dismissive and non-therapeutic.

B. This response uses therapeutic communication to explore the mother’s concerns without judgment, allowing for education and support.

C. Suggesting home-schooling may reinforce unnecessary restrictions and does not address the concern.

D. Agreeing outright does not help the mother understand that physical activity can be managed safely.

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