A nurse is out in public when an individual suddenly falls to the ground with a generalized tonic- clonic (grand mal) seizure.
Which action should the nurse take first?
Place a stick in the person’s mouth to prevent biting of the tongue and call for assistance.
Completely record time of the person’s seizure and save for paramedics.
Restrain the limbs to prevent injury while providing as much privacy for the person as possible.
Loosen the individual’s necktie after placing the person in the recovery position.
The Correct Answer is D
This is because the recovery position helps maintain the airway and prevent aspiration, and loosening the necktie prevents breathing restriction.
The other choices are wrong because:
Choice A is wrong because placing a stick or any object in the person’s mouth can cause injury to the teeth, gums, tongue or jaw and obstruct the airway. The person cannot swallow or bite their tongue during a seizure.
Choice B is wrong because recording the time of the seizure is not the first priority. The first priority is to ensure the safety and comfort of the person.
Choice C is wrong because restraining the limbs can cause injury or fracture, increase agitation and prolong the seizure. The nurse should protect the person from injury by moving furniture away and padding the head.
Normal ranges for seizure duration are usually less than 5 minutes for generalized tonic-clonic seizures and less than 15 seconds for absence seizures. If the seizure lasts longer than 5 minutes, or if the person has repeated seizures without regaining consciousness, it is considered a medical emergency and requires immediate treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should hold and notify the prescriber because hydrochlorothiazide is a diuretic that can lower the serum potassium level. The client already has a high serum potassium level of 5.2 mmol/L, which is above the normal range of 3.5 to 5.0 mmol/L.
Giving hydrochlorothiazide could worsen the client’s condition and cause hypokalemia.
Choice A is wrong because metoprolol is a beta-blocker that can lower the blood pressure and heart rate.
The client’s blood pressure and heart rate are not given, so there is no reason to hold metoprolol based on the information provided.
Choice C is wrong because enoxaparin is an anticoagulant that can prevent blood clots. The client has a low platelet count of 98,000/mm, which is below the normal range of 150,000 to 450,000/mm.
However, this does not contraindicate the use of enoxaparin, unless the client has signs of bleeding or bruising.
Choice D is wrong because atorvastatin is a statin that can lower the serum cholesterol
level. The client has a high serum cholesterol level of 250 mg/dL, which is above the desirable level of less than 200 mg/dL.
Giving atorvastatin could help reduce the client’s risk of cardiovascular complications.
Correct Answer is ["B","C","D"]
Explanation
Exercise has many health benefits, such as improving self-concept, decreasing resting pulse and blood pressure, and improving sleep quality.
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