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.

Answer and Explanation

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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Correct Answer is ["A","B","C","D","E","H","J"]

Explanation

WBC count 6,700/mm³ is unchanged from previous readings, remaining within normal limits, indicating no new or worsening infection or inflammatory response.
Hemoglobin 12 g/dL represents a significant increase from the previous value of 7.8 g/dL, demonstrating successful red blood cell transfusion and improvement in oxygen-carrying capacity.
Hematocrit 36% is also markedly improved from 24%, further confirming correction of anemia following transfusion.

Blood pressure 112/74 mm Hg has increased from a low of 76/45 mm Hg, indicating improved circulatory status and perfusion following fluid resuscitation and transfusion.
Heart rate 95/min is a decrease from previous tachycardic values (121/min), suggesting stabilization of hemodynamics and resolution of compensatory response to anemia and hypotension.
Oxygen saturation 100% on 2 L/min O₂ via nasal cannula confirms adequate oxygenation, demonstrating improved hemoglobin levels and effective oxygen delivery.

Respiratory: bilateral breath sounds clear confirms stable respiratory function, showing no complications such as fluid overload or transfusion-related lung injury.

A. The client's next dressing change is scheduled in 4 hr. B. The client's vital signs are checked every 8 hr. C. The client has developed difficulty ambulating. D. The client has state-sponsored health insurance.

Correct Answer is C

Explanation

A. The client's next dressing change is scheduled in 4 hr. While the next dressing change is relevant to nursing care, it may not be critical for all members of the interprofessional team. The focus of the meeting should be on issues that impact the overall care plan and interdisciplinary collaboration.
B. The client's vital signs are checked every 8 hr. Checking vital signs every 8 hours is more specific to nursing care and may not be necessary for other team members to know unless there are concerns related to the client's condition that could affect their care.
C. The client has developed difficulty ambulating. Difficulty ambulating is important for the interprofessional team as it impacts the client's mobility, safety, and overall care plan. Difficulty ambulating may require the involvement of physical therapy, occupational therapy, and adjustments to the care approach, making it a critical point for discussion.
D. The client has state-sponsored health insurance. Having state-sponsored health insurance is relevant to the financial and administrative aspects of care, but it may not directly influence the clinical care decisions made by the interprofessional team and may not need to be addressed during the meeting.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E","H","J"]

Explanation

A nurse is participating in an interprofessional team meeting for a client. Which of the following information about the client should the nurse include?

Correct Answer is C

Explanation

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