The nurse is performing the morning assessment on a patient. The patient suddenly screams loudly and begins to have a generalized tonic/clonic type seizure. What is the priority nursing intervention?
Place soft restraints on the patient
Place a padded tongue blade in the client's mouth
Turn the patient on the side and stay with them
Immediately go to the nurses' station for help
Respirations
The Correct Answer is C
A. Soft restraints are not recommended during a seizure and can cause harm to the patient.
B. Placing anything in the mouth during a seizure can lead to injury or airway obstruction and is contraindicated.
C. Turning the patient on their side helps to maintain an open airway and prevent aspiration; staying with the patient ensures ongoing monitoring.
D. Leaving the patient alone to seek help is unsafe, as it leaves the patient unmonitored during the seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Soft restraints are not recommended during a seizure and can cause harm to the patient.
B. Placing anything in the mouth during a seizure can lead to injury or airway obstruction and is contraindicated.
C. Turning the patient on their side helps to maintain an open airway and prevent aspiration; staying with the patient ensures ongoing monitoring.
D. Leaving the patient alone to seek help is unsafe, as it leaves the patient unmonitored during the seizure.
Correct Answer is C
Explanation
A. Suctioning can increase ICP due to the Valsalva response and should only be done if absolutely necessary.
B. Documenting without intervention could lead to worsening of the patient's condition.
C. Notifying the physician and raising the head of the bed helps to reduce ICP by promoting venous drainage. An ICP of 30 mmHg is critically high, requiring immediate intervention to prevent further damage.
D. Lowering the head of the bed can increase ICP further; head elevation is recommended to improve cerebral drainage.
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