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 B
Explanation
A. Expecting a patient to display preinjury personality traits may not be feasible, as head injuries can lead to permanent personality changes.
B. Actively participating in rehabilitation is a realistic goal that focuses on the patient's engagement in the recovery process, which can improve functional outcomes.
C. Returning to a specific job, such as a corporate attorney, may not be a realistic goal initially and depends on the extent of cognitive recovery.
D. Recalling childhood events is not a priority goal in rehabilitation; functional and recovery-focused goals are more relevant.
Correct Answer is B
Explanation
A. 1:1 observation may be excessive unless the behavior is persistent and unmanageable.
B. Pointing out the behavior as unacceptable provides immediate feedback and helps the patient understand social boundaries, which can be challenging post-brain injury. This approach is direct and respectful, focusing on redirection rather than punishment.
C. Asking why may not be effective, as the patient may lack insight into their behavior due to the brain injury.
D. Having the patient return to their room could seem punitive and does not address the need for behavior modification.
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