A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?
Turn the client's head to the side.
Check the client's motor strength.
Document the time the seizure began.
Loosen the clothing around the client's waist.
The Correct Answer is A
Turn the client's head to the side.
The nurse should turn the client's head to the side first to prevent aspiration of oral secretions and maintain a patent airway. This is the priority action according to the airway, breathing, and circulation (ABC) principle.
Check the client's motor strength is wrong because it is not the priority action and it is not feasible during a seizure. The nurse should check the client's motor strength after the seizure to assess for any neurological deficits or postictal weakness.
Document the time the seizure began is wrong because it is not the priority action and it can be done later. The nurse should document the time, duration, type, and characteristics of the seizure, but only after ensuring the client's safety and well-being.
Loosen the clothing around the client's waist is wrong because it is not the priority action and it may not be necessary. The nurse should loosen any tight clothing that could impair breathing or circulation, but only after securing the airway and protecting the head from injury.
Turn the client's head to the side.
The nurse should turn the client's head to the side first to prevent aspiration of oral secretions and maintain a patent airway. This is the priority action according to the airway, breathing, and circulation (ABC) principle.
Check the client's motor strength is wrong because it is not the priority action and it is not feasible during a seizure. The nurse should check the client's motor strength after the seizure to assess for any neurological deficits or postictal weakness.
Document the time the seizure began is wrong because it is not the priority action and it can be done later. The nurse should document the time, duration, type, and characteristics of the seizure, but only after ensuring the client's safety and well-being.
Loosen the clothing around the client's waist is wrong because it is not the priority action and it may not be necessary. The nurse should loosen any tight clothing that could impair breathing or circulation, but only after securing the airway and protecting the head from injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Planning to slow down if tired the day after exercising is a statement that indicates the client understands the importance of pacing activities and avoiding overexertion, which can worsen heart failure symptoms.
a. "I should use naproxen to manage discomfort." is not correct, as naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause fluid retention, increase blood pressure, and worsen heart failure. The client should avoid NSAIDs and use other analgesics, such as acetaminophen, unless contraindicated.
c. "I will read food labels and limit my sodium to 4 grams per day." is not appropriate, as 4 grams of sodium per day is too high for a client who has congestive heart failure. The client should limit sodium intake to 2 grams or less per day, as sodium can cause fluid retention and increase the workload of the heart.
d. "I will take my diuretic before sleep and drink fluids during the day." is not advisable, as taking a diuretic before sleep can cause nocturia and disrupt the sleep cycle, which can affect the quality of life and cardiac function. The
Correct Answer is D
Explanation
Nitroglycerin is a vasodilator that relaxes smooth muscle in blood vessels and reduces myocardial oxygen demand. It is used to treat and prevent angina atacks. A common side effect of nitroglycerin is headache, which is caused by cerebral vasodilation. The nurse should advise the client to take a mild analgesic, such as acetaminophen, to relieve the headache. The headache usually subsides with continued use of nitroglycerin.
The other options are not correct because:
"Take only one dose of nitroglycerin to reduce the risk of getting a headache." This statement is incorrect because it may compromise the effectiveness of nitroglycerin in relieving angina. The client should follow the prescribed dosage and frequency of nitroglycerin, which is usually one tablet every 5 minutes for up to three doses, as needed for chest pain.
"There's nothing that can be done to relieve the headaches that nitroglycerin causes." This statement is incorrect because it is discouraging and dismissive of the client's concern. The nurse should acknowledge the client's
discomfort and offer suggestions for managing the side effect, such as taking a mild analgesic or lying down in a dark room.
"We will ask the provider to prescribe a different medication for you." This statement is incorrect because it implies that nitroglycerin is not suitable for the client and may cause unnecessary anxiety or confusion. The nurse should explain that nitroglycerin is an effective and safe medication for angina and that the headache is a common and transient side effect that can be managed with simple measures. The nurse should also inform the client that there are other forms of nitroglycerin, such as patches or sprays, that may have less headache-inducing effects. However, changing the medication or the route of administration should be done only after consulting with the provider.
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