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 bears weight on both feet when moving the walker ahead and steps with the weaker leg first. This is the proper way to use a walker for ambulation, as it provides stability and reduces stress on the affected joints.
Choice A is wrong because the client should not look down at his feet to prevent falling, but rather look ahead at where he is going. Looking down can cause neck strain and loss of balance.
Choice C is wrong because the client should not place her full weight on the walker with her arms while taking steps, as this can cause upper extremity fatigue and injury. The client should use the walker as a support, not a crutch.
Choice D is wrong because the client should not lean forward at a 60-degree angle while stepping into the walker, as this can cause back pain and poor posture. The client should stand upright and move the walker forward about one step’s length at a time.
Correct Answer is C
Explanation
This is because responding inappropriately to questions can indicate that the client has difficulty hearing or understanding what is being asked. According to, hearing loss makes communication with the outside world difficult, and can result in new or exaggerated symptoms that are mistakenly attributed to cognitive decline.
Choice A is wrong because speaking in a low voice does not necessarily imply hearing loss. It could be due to other factors such as shyness, anxiety, or vocal cord problems.
Choice B is wrong because refusing to answer questions does not necessarily imply hearing loss.
It could be due to other factors such as lack of interest, defiance, or distrust.
Choice D is wrong because looking away from persons while speaking does not necessarily imply hearing loss.
It could be due to other factors such as cultural norms, eye contact avoidance, or distraction.
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