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?

Check the client’s motor strength.

Turn the client’s head to the side.

Document the time the seizure began.

Loosen the clothing around the client’s waist.

Answer and Explanation

The Correct Answer is B

A: Checking the client’s motor strength is not the first priority during a seizure. Ensuring the client’s safety and airway patency is more important.

B: Turning the client’s head to the side is the first action. This helps maintain an open airway and prevents aspiration of saliva or vomit.

C: Documenting the time the seizure began is important for medical records but is not the immediate priority during the seizure.

D: Loosening the clothing around the client’s waist can help with comfort but is not the first action to take during a seizure.

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Correct Answer is A

Explanation

A: The correct instruction is to hold the cane on the right side, which is the side opposite the weaker leg. This provides better support and balance for the weaker side.

B: Removing the rubber tip from the cane is not recommended. The rubber tip provides traction and stability, reducing the risk of slipping.

C: Advancing the right leg and the cane together is incorrect. The cane should move with the weaker leg (left leg in this case) to provide support during ambulation.

D: Placing the cane 61 cm (24 in) in front of the feet is too far. The cane should be placed about 15-25 cm (6-10 in) in front of the feet to provide optimal support and balance.

A. Hyperkalemia B. Hyponatremia C. Hypervolemia D. Hypovolemia

Correct Answer is C

Explanation

A: Hyperkalemia refers to high potassium levels, which can occur in ESKD but does not directly cause shortness of breath, swelling, or crackles in the lungs.

B: Hyponatremia refers to low sodium levels, which can occur in ESKD but does not directly cause the symptoms described.

C: Hypervolemia, or fluid overload, is the most likely cause of the client’s symptoms. ESKD can lead to fluid retention, causing shortness of breath, swelling, crackles in the lungs, and elevated blood pressure.

D: Hypovolemia refers to low blood volume, which would not cause the symptoms of fluid overload described in the client.

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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?

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