A client on alcohol withdraw protocol suddenly begins to have a seizure in his bed. After several minutes the seizure has not ended and the nurse suspects the client is suffering from status epilepticus. What is the priority action the nurse will take?
administer IV lorazepam
lower the client to the floor
allow the client to seize for up to 10 minutes
call a code
The Correct Answer is A
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale; When a client requests pain medication, the first action the nurse should take is to assess the client's current pain level. By using a pain scale, the nurse can determine the intensity of the pain and evaluate the need for pain medication appropriately. The pain scale allows the client to express their pain on a standardized scale, helping the nurse to understand the severity of the pain and the most appropriate pain management intervention.
Choice B rationale: While diversional thoughts and non-pharmacological pain management techniques can be useful, the priority is to first assess the pain level and address the client's immediate needs for pain relief.
Choice C rationale: While it's important to consider the client's history of drug use, it is not the first action to take when a client requests pain medication. Assessing the pain level and providing appropriate pain relief should be the initial priority.
Choice D rationale: While it's essential to know the last dose of pain medication the client received, it is not the first action to take when the client is requesting pain medication. Assessing the current pain level and addressing the client's immediate needs should be the first step. The information about the last dose will be relevant for deciding when the next dose can be given.
Correct Answer is C
Explanation
Choice A rationale: Checking the capillary glucose level is not relevant to the observation of yellow skin color. Jaundice is related to liver function, not glucose levels.
Choice B rationale: Oxygen saturation measurement is not relevant to the observation of yellow skin color. It is used to assess the oxygen-carrying capacity of the blood, not liver function.
Choice C rationale: Yellow discoloration of the skin (jaundice) can be indicative of liver dysfunction or damage. Since the client takes acetaminophen for chronic pain, which is metabolized in the liver, the nurse should be concerned about potential hepatotoxicity. Reporting the findings to the healthcare provider is essential for further evaluation and management.
Choice D rationale: Reducing the medication dose is not appropriate without further evaluation and guidance from the healthcare provider. Jaundice may indicate liver dysfunction, and altering the medication without professional assessment could be unsafe.
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