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 A
Explanation
A toileting routine is the priority intervention for a client diagnosed with total urinary incontinence because it helps to prevent skin breakdown, infection, and odor. It also promotes dignity and comfort for the client.
Choice B. Kegel exercises are wrong because they are not effective for total urinary incontinence, which is the complete loss of bladder control. Kegel exercises are more useful for stress or urge urinary incontinence, which are caused by weak pelvic floor muscles.
Choice C. Surgery is wrong because it is not a priority intervention for total urinary incontinence.
Surgery may be considered a last resort option if other conservative measures fail to improve the condition. Surgery may also have risks and complications that need to be weighed against the benefits.
Choice D. Anticholinergic drug therapy is wrong because it is not a priority intervention for total urinary incontinence.
Anticholinergic drugs are used to treat overactive bladder or urge urinary incontinence, which are caused by involuntary bladder contractions. Anticholinergic drugs may have side effects such as dry mouth, constipation, blurred vision, and confusion.
Correct Answer is C
Explanation
The nurse should complete an incident report when he or she contaminates and discards two indwelling catheters during the insertion procedure. This is because an incident report is a tool for documenting any event that is not consistent with the routine operation of a health care unit or the routine care of a client. An incident report helps to identify potential risks and improve quality and safety.
Choice A is wrong because not completing the care plan for a newly admitted client before leaving the unit is not an incident that requires reporting.
It is a matter of time management and prioritization.
Choice B is wrong because recording a client’s refusal to take prescribed medication on the chart is not an incident that requires reporting.
It is a part of the nursing documentation and communication.
Choice D is wrong because experiencing back pain after moving a client up in the bed is not an incident that requires reporting.
It is a personal injury that may be related to improper body mechanics or ergonomics.
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