Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is in a client's room when the client begins having a tonicclonic seizure. Which of the following actions should the nurse take first?
A. Document the time the seizure began.
Documenting the time the seizure began is important, but not the first priority. The nurse should document the onset, duration, type, and characteristics of the seizure after ensuring the client's safety and airway patency.
B. Turn the client's head to the side.
Turning the client's head to the side is the first action that the nurse should take to prevent aspiration of saliva or vomitus and maintain a patent airway during a seizure. The nurse should also protect the client from injury by removing any objects that could harm them and placing a soft pad under their head.
C. Check the client's motor strength.
Checking the client's motor strength is not relevant during a seizure, as the client will have involuntary muscle contractions and loss of consciousness. The nurse should assess the client's neurological status after the seizure has ended and they have regained consciousness.
D. Loosen the clothing around the client's waist.
Loosening the clothing around the client's waist is a helpful measure, but not as urgent as turning their head to the side. Loosening clothing can prevent restriction of breathing andcirculation during a seizure, but it does not address airway patency or aspiration risk.
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg adult care 2 proctored exam. Take the full exam now
Similar Questions
A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?
A. Perform a Romberg's test.
Correct. A Romberg's test is used to assess balance and coordination, which are impaired in clients with ataxia. The nurse should ask the client to stand with feet together and arms at the sides, first with eyes open and then with eyes closed. The nurse should observe for swaying or loss of balance.
B. Observe for the presence of Kernig's sign.
Incorrect. Kernig's sign is a sign of meningeal irritation, not ataxia. It is elicited by flexing the client's hip and knee to 90 degrees and then attempting to extend the leg. A positive sign is pain and resistance to leg extension.
C. Inspect for the presence of clubbing.
Incorrect. Clubbing is a sign of chronic hypoxia, not ataxia. It is characterized by an increased angle between the nail and the nail bed, and a spongy feeling of the nail base.
D. Check the function of cranial nerve V.
Incorrect. Cranial nerve V is the trigeminal nerve, which innervates the muscles ofmastication and provides sensory input from the face, scalp, and oral cavity. It is not related to ataxia or ambulation.
When considering the client with a neurocognitive deficit, the nurse understands that which of the following are excitatory neurotransmitters?
A. GABA
Incorrect. GABA (gammaaminobutyric acid) is an inhibitory neurotransmitter that reduces neuronal activity and has a calming effect on the brain.
B. Norepinephrine
Correct. Norepinephrine is an excitatory neurotransmitter that increases arousal, alertness, and attention.
C. Dopamine
Correct. Dopamine is an excitatory neurotransmitter that modulates motivation, reward, and movement.
D. Serotonin
Incorrect. Serotonin is a neurotransmitter that has both excitatory and inhibitory effects, depending on the receptor type and location. It is involved in mood regulation, sleep, appetite, and pain perception.
A client with multiple sclerosis has been prescribed interferon B. Which of the following statements indicates the client understands the teaching about this medication.
A. I should inject the medicine in the same location each day
This is incorrect. The client should rotate the injection sites to prevent skin irritation and necrosis.
B. If I feel depressed, I will call the doctor
This is correct. Interferon B can cause depression and suicidal ideation, so the client should monitor their mood and seek help if needed.
C. When I become pregnant the dose will be reduced.
This is incorrect. Interferon B is contraindicated in pregnancy and breastfeeding, so the client should use effective contraception and inform the doctor if they plan to conceive or become pregnant.
D. I should call the doctor if I feel like I have the flu
This is incorrect. Flulike symptoms are common side effects of interferon B and usually subside after a few weeks of therapy. The client can take acetaminophen or ibuprofen to reduce fever and pain.