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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Bradypnea is not a hallmark sign of ARDS; ARDS typically involves tachypnea or rapid breathing.
B. An elevated PaCO2 indicates hypercapnia but is not specific to ARDS.
C. Elevated blood pressure is not a specific indicator of ARDS.
D. A persistently low PaO2 despite receiving high-flow oxygen (such as from a non-rebreather mask) is a hallmark sign of ARDS, indicating severe hypoxemia and impaired gas exchange.
Correct Answer is B
Explanation
A. Controlling impulsive behavior is more relevant to right hemispheric strokes, which often affect impulse control and behavior.
B. A left hemispheric CVA often affects language and communication skills, making it crucial to focus on improving these abilities.
C. Loss of depth perception is more associated with right hemispheric strokes.
D. Motor function improvement for the affected side (right side for left hemispheric stroke) is important, but communication deficits are a primary focus for left hemispheric strokes.
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