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"}
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- Place a tongue blade in the client’s mouth: This is unsafe and outdated.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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Decrease background noise: Reducing ambient noise helps clients with hearing loss focus better on the speaker’s voice, minimizing distractions and enhancing their ability to interpret sounds or speech through residual hearing or lip-reading.
B. Speak in a loud voice: Speaking loudly can distort speech sounds and facial expressions, making it harder for clients to understand. It’s more effective to speak clearly at a moderate pace and volume.
C. Use short phrases: While shorter phrases might seem easier to process, effective communication often depends on clear context and full sentences. Using natural language helps convey meaning more accurately.
D. Talk at a rapid rate: Rapid speech can be difficult for individuals with hearing loss to follow, especially if they rely on lip-reading. Slower, clearer speech improves understanding and facilitates better communication.
Correct Answer is A
Explanation
A. Hyponatremia: Vomiting and diarrhea cause significant fluid loss, often leading to a decrease in sodium levels in the blood (hyponatremia) due to loss of electrolytes and dilution from fluid replacement or retained water.
B. Hyperkalemia: Vomiting and diarrhea usually cause potassium loss, resulting in hypokalemia rather than hyperkalemia, as potassium is lost through gastrointestinal fluids.
C. Hypocalcemia: Calcium levels are generally not directly affected by vomiting and diarrhea, so hypocalcemia is less likely in this scenario.
D. Hypermagnesemia: Magnesium is typically lost with gastrointestinal losses; therefore, hypermagnesemia is uncommon with vomiting and diarrhea.
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