A nurse enters a client's room and finds the client experiencing a seizure on the floor. Which of the following actions should the nurse take?
Place a pillow under the client's head.
Gently restrain the client's arms.
Administer a muscle relaxant.
Insert a tongue blade.
The Correct Answer is A
A. Place a pillow under the client's head. Placing a pillow under the client's head is appropriate as it helps protect the client's head from injury during the seizure. Providing cushioning can reduce the risk of head trauma, which is a common concern during seizures.
B. Gently restrain the client's arms. Gently restraining the client's arms is not recommended during a seizure, as it can lead to injury. Restraining movements can also increase the risk of injury to both the client and the caregiver. Instead, the nurse should allow the seizure to progress without interference.
C. Administer a muscle relaxant. Administering a muscle relaxant is not appropriate during a seizure. The nurse should not medicate the client until the seizure has stopped and the healthcare provider has assessed the situation. Immediate management focuses on safety rather than medication.
D. Insert a tongue blade. Inserting a tongue blade or any object into the client's mouth is dangerous and not recommended. This can cause oral injury, broken teeth, or airway obstruction. The nurse should ensure the area is clear of hazards and allow the seizure to occur without attempting to prevent movements.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I've been wearing the same few things every day because most of my clothes don't fit anymore." This statement reflects a common experience during pregnancy as the body changes. While it may indicate some frustration, it does not necessarily suggest difficulty accepting body image changes.
B. "Dressing up for work is a little harder now that I can't wear high heels." This statement acknowledges an adjustment in clothing choices due to pregnancy but does not indicate distress about body image. Many individuals modify their footwear for comfort and safety as pregnancy progresses.
C. "I've had to start wearing nursing bras already because my breasts are growing so much." This statement reflects awareness of bodily changes rather than difficulty accepting them. Breast enlargement is a normal part of pregnancy, and choosing appropriate clothing to accommodate these changes suggests adaptation rather than distress.
D. "When I wear high-top yoga pants, they hold my belly in so you can't even tell I'm pregnant." This statement suggests an attempt to conceal the pregnancy, which may indicate discomfort with body image changes. Actively trying to hide the pregnancy rather than embracing the natural progression of body changes can be a sign of difficulty accepting the physical transformation.
Correct Answer is ["A","B","D","E"]
Explanation
A. Communicate advance directives status via the medical record and shift report. The nurse is responsible for ensuring that all members of the healthcare team are aware of the client’s advance directives. Documenting this information in the medical record and shift report helps guide care in accordance with the client’s wishes.
B. Provide the client with written information about advance directives. Clients have the right to receive information about advance directives, including living wills and do-not-resuscitate (DNR) orders. The nurse should provide educational materials to help the client make informed decisions.
C. Inform the client that an advance directive discontinues further care. An advance directive does not automatically discontinue all medical care. It provides instructions regarding specific interventions the client wishes to accept or decline, such as resuscitation, mechanical ventilation, or artificial nutrition. The nurse should clarify this to avoid misconceptions.
D. Instruct the client that an advance directive is a legal document and must be honored by care providers. Advance directives are legally binding documents that must be followed by healthcare providers. The nurse should reinforce that the client’s wishes, as stated in the directive, will be respected.
E. Document that the provider discussed do-not-resuscitate status with the client. Proper documentation is essential to ensure the client's preferences regarding resuscitation and end-of-life care are acknowledged and followed. The nurse should record discussions regarding advance directives in the medical record.
F. Initiate a power of attorney for health care document. The nurse does not have the authority to initiate a power of attorney for health care. The client must complete this legal document independently or with legal assistance, and it typically requires notarization or witness signatures. The nurse can provide information about it but cannot create or execute it on the client’s behalf.
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