Which nursing intervention takes priority for the client having a tonic-clonic seizure?
Inserting a padded tongue blade to prevent the client from biting his tongue.
Maintaining a patent airway
Timing the duration of the seizure
Noting the origin of seizure activity
The Correct Answer is B
A. Inserting a tongue blade is contraindicated as it can cause injury or airway obstruction.
B. Maintaining a patent airway is the highest priority to ensure adequate oxygenation during a seizure.
C. Timing the seizure is important for documentation but secondary to airway management.
D. Noting the origin of seizure activity helps with diagnosis but is not an immediate priority during the seizure.
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Related Questions
Correct Answer is C
Explanation
A. A brief loss of consciousness with staring is characteristic of absence seizures, not an aura.
B. A period of sleepiness or confusion after a seizure is known as the postictal phase, not an aura.
C. An aurais a sensory warning sign(e.g., visual changes, strange smells, or feelings) that a seizure is about to occur. It is considered part of the seizure itself and can help predict its onset.
D. A continuous seizure state is known as status epilepticus, which is a medical emergency, but unrelated to the concept of an aura.
Correct Answer is C
Explanation
A. Kernig signis elicited by flexing the client's hip and knee, then straightening the leg. Pain or resistanceindicates meningeal irritation.
B. Nuchal rigidityrefers to stiffness of the neck, a classic sign of meningitis, but it does not involve reflexive leg movement.
C. Brudzinski’s signis positive when passive neck flexion causes involuntary flexion of the hips and knees. It is a classic indicator of meningeal irritation, such as in meningitis.
D. Bradykinesiarefers to slowness of movement, typically seen in Parkinson’s disease, not meningitis.
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