A nurse is assisting in the care of a client.
Complete the following sentence by using the lists of options.
At 1000 the nurse enters the client's room. The first action the nurse should take is
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Correct answers: At 1000 the nurse enters the client's room. The first action the nurse should take is call for assistance followed by turn the client to their side.
i. call for assistance: According to the nursing process, once a seizure begins (the ictal phase), the nurse must ensure they have help to manage the client's safety and monitor the event. The nurse should stay with the client but call for another staff member to bring emergency equipment or notify the provider.
ii. turn the client to their side: This is the priority safety intervention during a generalized tonic-clonic seizure. Turning the client to a lateral position helps maintain a patent airway and prevents aspiration of oral secretions or vomitus.
Rationale for incorrect answers:
remove the pillows: While removing pillows can help prevent airway occlusion if the head is hyper-flexed, calling for help and positioning the client on their side are higher priorities in the sequence of emergency management.
reorient the client: This occurs during the postictal phase (after the seizure has ended) when the client is regaining consciousness, not during the active seizure at 1000.
administer anticonvulsant medications: While medications like IV lorazepam may be indicated if a seizure is prolonged (status epilepticus), the immediate physical safety and airway management are the first nursing actions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. Photo identification: In many long-term care settings, a photo is used as a secondary identifier for clients who may be confused or non-verbal.
B. Room number: Room numbers are never used as identifiers because clients can be moved or transferred between rooms.
C. Facility-assigned identification number: This is a unique number assigned to the specific client upon admission.
D. Diagnosis: Multiple clients on a unit may share the same diagnosis (e.g., CHF or Diabetes).
E. Date of birth: This is a standard, unique identifier used in conjunction with the client's name.
Correct Answer is C
Explanation
A. Ask the client why they're unable to cope.: As noted previously, "Why" questions are non-therapeutic and can make the client feel defensive or judged.
B. Tell the client to think about something else.: This is a dismissive response that avoids the client's feelings and provides a false sense of a solution.
C. Ask the client to describe their support system.: Identifying a support system is a key step in the assessment of coping. It helps the client identify resources they can lean on during a crisis.
D. Tell the client that everything will be okay.: This is false reassurance, which is non-therapeutic because it discourages the client from expressing their actual concerns and is not a factual statement the nurse can guarantee.
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