The nurse is at bedside with a client who started having a tonic-clonic seizure. Which of the following actions should the nurse implement first during the ictal stage?

Turn the client on their side

Administer 1 mg of IV lorazepam

Administer oxygen via a nonrebreather mask

Assess the client’s level of consciousness

Answer and Explanation

The Correct Answer is A

Choice A reason: Turning the client on their side during a tonic-clonic seizure ensures airway patency by preventing aspiration of secretions. This is the first priority for safety, making it the correct action.

Choice B reason: Administering lorazepam stops seizures but is secondary to ensuring a clear airway. Safety during the ictal phase prioritizes positioning, making this incorrect as the first action.

Choice C reason: Oxygen administration is supportive but not the first action. Maintaining an open airway by positioning prevents aspiration, making this incorrect compared to turning the client.

Choice D reason: Assessing consciousness is irrelevant during the active seizure phase. Protecting the airway through positioning is the priority, making this incorrect as the first intervention.

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Correct Answer is B

Explanation

Choice A reason: Rationalization involves justifying behavior with logical excuses, not blaming others. The client attributes their failure to their partner, which is projection, making this incorrect for the defense mechanism.

Choice B reason: Projection involves attributing one’s own shortcomings, like forgetting medication, to another person, such as the partner. The client blames their partner, making this the correct defense mechanism.

Choice C reason: Repression is unconsciously blocking distressing thoughts, not blaming others. The client openly acknowledges the missed medication, so this is incorrect for the observed behavior.

Choice D reason: Regression involves reverting to childish behaviors, not blaming others. The client’s statement reflects externalizing responsibility, fitting projection, making this incorrect for the defense mechanism.

A. Hyperglycemia B. Raccoon eyes C. Battle’s sign D. Positive halo sign test result

Correct Answer is A

Explanation

Choice A reason: Hyperglycemia is not a sign of a basilar skull fracture. It may occur in critical illness due to stress responses or diabetes but is not directly linked to skull fractures. Basilar skull fractures cause physical signs like cerebrospinal fluid leakage or bruising, not metabolic disturbances like elevated blood sugar.

Choice B reason: Raccoon eyes, or periorbital ecchymosis, are a hallmark sign of a basilar skull fracture. Blood from fractured cranial bones pools around the eyes due to gravity, indicating trauma to the skull base. This results from vascular disruption and is a specific clinical finding in such injuries.

Choice C reason: Battle’s sign, or mastoid ecchymosis, is a classic sign of a basilar skull fracture. Blood tracks behind the ear due to fracture-related hemorrhage in the posterior cranial fossa. This physical sign is highly specific and results from bone disruption near the mastoid process.

Choice D reason: A positive halo sign test result indicates cerebrospinal fluid leakage, a common feature of basilar skull fractures. The clear fluid mixed with blood forms a halo-like ring on absorbent material, reflecting a breach in the dura mater, making it a specific diagnostic sign.

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The nurse is at bedside with a client who started having a tonic-clonic seizure. Which of the following actions should the nurse implement first during the ictal stage?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who states, “I did not take my medication because my partner forgot to remind me.” The nurse should identify that the client is demonstrating which of the following defense mechanisms?

Correct Answer is B

Explanation

Which of the following is not a sign of a basilar skull fracture?

Correct Answer is A

Explanation

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