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. 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.
Correct Answer is B
Explanation
A. Simple partial (focal aware) seizures do not alter consciousness; that is a characteristic of complex partial seizures.
B. Focal (partial) seizures typically affect one hemisphereof the brain and therefore one side of the body.
C. Seizures that begin with motor impairment in all extremitiessuggest a generalized seizure, not a simple partial seizure.
D. This is inaccurate. Simple partial seizures are treatablewith antiepileptic medications and sometimes surgical interventions.
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