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
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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
A. While anxiety can cause gastrointestinal symptoms, the context of this patient’s experience with seizures indicates that it is specifically related to the seizure disorder rather than an independent anxiety issue.
B. The sensation of "butterflies" is not typically related to hunger, as hunger is more commonly associated with physical feelings of emptiness or pain rather than a specific butterfly sensation.
C. An aura is a perceptual disturbance experienced by some patients with seizure disorders that precedes a seizure. It can manifest as various sensations, including gastrointestinal feelings like "butterflies," which serve as a warning sign that a seizure is imminent.
D. A postictal sign refers to the state of confusion or altered consciousness following a seizure, rather than sensations experienced prior to the seizure.
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.