A nurse is assisting in the care of a client.

Exhibits

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
dropdown
followed by
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Rationale for Correct Answers:

Turn the client to their side: This is a crucial first action. During a seizure, turning the client to their side (recovery position) helps to maintain an open airway, prevent aspiration of saliva or vomitus, and allow secretions to drain from the mouth.
Call for assistance: After ensuring the client's safety and positioning, the nurse should call for help to ensure appropriate and prompt support from the healthcare team.

Rationale for Incorrect Answers:

Restrain the client: Restraining a client during a seizure can cause injury. Instead, ensure the area is safe and the client is protected from harm without restricting movement.
Place a tongue blade in the client’s mouth: This is unsafe and outdated. Inserting anything in the mouth during a seizure can break teeth or obstruct the airway.
Administer lorazepam: Although lorazepam is used to treat ongoing prolonged seizures, it is not the first action in this scenario. Medication administration follows basic safety measures and calling for support.

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Correct Answer is C

Explanation

A. Hypoactivity: Hypoactive bowel sounds refer to reduced or diminished intestinal activity, often indicating slowed motility. These sounds are usually soft, infrequent, or absent, which contrasts with the loud, growling sounds described in this scenario.

B. Paralytic ileus: Paralytic ileus is a condition characterized by the absence of intestinal motility, resulting in no bowel sounds on auscultation. The presence of loud growling sounds indicates active bowel movements, making paralytic ileus an unlikely term.

C. Borborygmi: Borborygmi describes the loud, rumbling, growling, or gurgling sounds caused by the movement of gas and fluids through the intestines. These sounds are normal but can be louder than usual in cases of increased gastrointestinal activity, such as hunger or diarrhea.

D. Distention: Distention refers to the visible swelling or enlargement of the abdomen, often due to gas, fluid, or mass accumulation. It is a physical finding observed visually or by palpation, not a term for a type of bowel sound heard during auscultation.

A. "Don't worry. Everything will work out for you." B. "We should talk about your decision later." C. "How will you discuss this decision with your loved ones?" D. "Your quality of life will be compromised if you make this decision."

Correct Answer is C

Explanation

A. "Don't worry. Everything will work out for you.": This response minimizes the client’s feelings and concerns, potentially invalidating their decision. It also avoids addressing the seriousness of the situation and does not encourage open communication or support.

B. "We should talk about your decision later.": Deferring the conversation may make the client feel ignored or unsupported. It is important to acknowledge and explore the client’s feelings and reasoning about discontinuing treatment promptly to provide appropriate care.

C. "How will you discuss this decision with your loved ones?": This response respects the client’s autonomy and opens a supportive dialogue. It encourages the client to consider communication with their support system and reflects a willingness to assist in the emotional and practical aspects of their decision.

D. "Your quality of life will be compromised if you make this decision.": This statement is judgmental and may induce guilt or fear. It does not respect the client’s right to make informed decisions about their own care and can hinder therapeutic communication.

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A nurse is assisting in the care of a client. Exhibits 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 dropdown followed by dropdown .

Nursing Test Bank

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A nurse is collecting data about a client's gastrointestinal system. While auscultating the abdomen, the nurse notes loud growling sounds. When documenting these findings, the nurse should use which of the following terms?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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A nurse is assisting in the care of a client.

Exhibits

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
dropdown
followed by
dropdown
.