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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
A: A client with lactose intolerance does not have an increased risk of aspiration while eating. Lactose intolerance affects the digestive system, causing symptoms like bloating and diarrhea when consuming dairy products, but it does not impact swallowing.
B: A client who has had a cerebrovascular accident (CVA) or stroke is at increased risk of aspiration. Strokes can affect the muscles involved in swallowing, leading to dysphagia (difficulty swallowing) and increasing the risk of food or liquid entering the airway.
C: A client who has had prolonged diarrhea is not typically at increased risk of aspiration. Diarrhea affects the gastrointestinal system but does not directly impact the swallowing mechanism.
D: A client who has had trauma to the head and neck is at increased risk of aspiration. Such trauma can damage the structures involved in swallowing, leading to dysphagia and a higher likelihood of aspiration.
E: A client who is 4 hours postoperative following a leg amputation with general anesthesia is at increased risk of aspiration. General anesthesia can depress the gag reflex and swallowing function, making it easier for food or liquid to enter the airway during the immediate postoperative period.
Correct Answer is C
Explanation
A: Keeping a fluorescent ceiling light on at night can be too bright and disrupt sleep. A nightlight is a better option for safety without disturbing sleep.
B: Keeping the walker at the end of the bed is not ideal. The walker should be within easy reach to prevent falls when getting out of bed.
C: Placing a bath seat in the shower is a good safety measure. It provides stability and reduces the risk of slipping and falling while bathing.
D: Placing an area rug at the entry of the bathroom can be a tripping hazard. It is better to use non-slip mats that are securely placed.
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