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 client practices meditation for 20 minutes once a day. This is an example of an adaptive coping strategy, which is a cognitive or behavioral effort to manage stressful conditions or associated emotional distress.
Meditation can help reduce tension, enhance relaxation, and promote well-being.
Choice A is wrong because the client consumes 3 glasses of wine after a stressful day at work. This is an example of an avoidance coping strategy, which is an attempt to reduce stress by avoiding dealing directly with the problem.
Alcohol consumption can have negative effects on physical and mental health, and does not address the source of stress.
Choice C is wrong because the client keeps all unresolved conflict to themselves. This is an example of an emotion-focused coping strategy, which is an attempt to regulate the emotional distress caused by a stressor.
However, this strategy can be maladaptive if it involves suppressing or denying emotions, which can lead to increased psychological distress and poor interpersonal relationships.
Choice D is wrong because the client consumes a half gallon of ice cream after an argument with a coworker. This is another example of an avoidance coping strategy, which is an attempt to reduce stress by avoiding dealing directly with the problem.
Ice cream consumption can have negative effects on physical health, such as obesity and diabetes, and does not address the source of stress.
Correct Answer is ["B","D"]
Explanation
Clubbing in upper digits and tripod positioning are signs of chronic obstructive pulmonary disease (COPD), a respiratory disorder that has components of chronic bronchitis and emphysema. Clubbing is a thickening and widening of the fingertips and nails due to chronic low oxygen levels in the blood. Tripod positioning is when the person leans forward and supports their arms on a table or chair to facilitate breathing.
Choice A is wrong because a BMI greater than 30% indicates obesity, which is not a specific sign of COPD, although it can worsen the condition.
Choice C is wrong because AP chest diameter of 1:1 means that the chest is as wide as it is deep, which is also known as barrel chest. This is a sign of emphysema, one of the components of COPD, but not of COPD itself.
Choice E is wrong because high amounts of energy are not associated with COPD. On the contrary, people with COPD often experience fatigue, weakness, and reduced exercise tolerance due to impaired gas exchange and respiratory muscle function.
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