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 A

Explanation

A. Cardiac enzyme tests, such as troponin and creatine kinase-MB, are used to assess the extent of myocardial damage. Elevated levels of these enzymes indicate that heart muscle cells have been injured or have died.
B. Cardiac enzymes do not localize the MI; imaging studies like echocardiography or coronary angiography are required to identify the specific location of myocardial damage.
C. Pulmonary congestion is assessed using chest X-rays or clinical symptoms, not through cardiac enzyme levels.
D. Cardiac enzyme tests do not provide information about the structure or mobility of heart valves. This information is obtained through echocardiography or other imaging techniques.

A. Deflate the balloons for 5 min every 2 hr to prevent tissue necrosis B. Suction the tube every 2 hr and as needed to maintain patency C. Maintain constant observation while the balloons are inflated D. Keep the head of the bed flat at all times to prevent the development of shock

Correct Answer is C

Explanation

A. Deflating the balloons regularly is not a standard practice and could potentially lead to rebleeding; balloon inflation should be managed carefully as per protocol.
B. Suctioning the tube should be done based on the need for patency, but every 2 hours might not be necessary unless indicated.
C. Maintaining constant observation while the balloons are inflated is crucial to monitor for complications such as esophageal tissue necrosis and to ensure effective hemostasis.
D. The head of the bed should typically be elevated to reduce the risk of aspiration and facilitate breathing, rather than kept flat.

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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?

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Naxlex Comprehensive Predictor Exams

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