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?

Document the time the seizure began.

Turn the client's head to the side.

Loosen the clothing around the client's waist.

Check the client's motor strength.

Answer and Explanation

The Correct Answer is B

A. Documenting the time of the seizure is important but is not the immediate priority. The priority is to ensure the client's safety during the seizure.

B. Turning the client's head to the side is the first action to take during a seizure. This helps prevent aspiration and keeps the airway clear by allowing any secretions to drain from the mouth.

C. Loosening clothing around the client's waist is important for comfort but should be done after ensuring the client's immediate safety. The primary focus should be on airway protection and preventing injury.

D. Checking the client's motor strength is not immediately relevant during an active seizure. The priority is to manage the seizure and ensure the client's safety, with detailed assessments to follow once the seizure has ended.

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Correct Answer is B

Explanation

A. Clients with hepatitis B should never donate blood, even after completing treatment, as they can remain carriers of the virus.
B. Resting frequently is essential for clients with hepatitis B as it helps the body recover and conserve energy during the healing process.
C. A high-protein diet is not recommended for hepatitis B patients; a balanced diet with adequate calories and nutrients is more appropriate to support liver health.
D. Acetaminophen is metabolized by the liver and should be used cautiously or avoided in clients with hepatitis B to prevent further liver damage.

A. Heart rate B. BP C. Weight D. Urine output

Correct Answer is A

Explanation

A. A decrease in heart rate can indicate adequate fluid resuscitation as it suggests improved circulatory status and reduced compensatory tachycardia, which is a response to hypovolemia.
B. An increase, rather than a decrease, in blood pressure would typically indicate improved fluid status and perfusion following adequate fluid resuscitation.
C. Weight changes are not an immediate indicator of fluid resuscitation adequacy. Weight reflects overall fluid balance over a longer period.
D. An increase, not a decrease, in urine output is expected with adequate fluid resuscitation, as improved renal perfusion results in better urine production.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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