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- Place a tongue blade in the client’s mouth: This is unsafe and outdated.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 C
Explanation
A. Registered dietitian: A dietitian can assess nutritional needs and recommend appropriate diets based on swallowing ability, but they do not directly evaluate or treat swallowing disorders. Their role becomes relevant after the dysphagia has been assessed and a safe diet established.
B. Respiratory therapist: Respiratory therapists focus on managing breathing and airway clearance, which can be important if aspiration pneumonia occurs. However, they do not assess or treat the swallowing difficulties themselves.
C. Speech-language pathologist: Speech-language pathologists evaluate and treat swallowing disorders as well as communication impairments following stroke. They perform swallowing assessments and develop individualized therapy plans to improve swallowing safety and function.
D. Occupational therapist: Occupational therapists assist clients with regaining independence in activities of daily living but do not specialize in swallowing assessments or treatments. Their focus is more on motor skills, cognition, and adaptive strategies.
Correct Answer is C
Explanation
A. "I'll use focused breathing to control my pain." Focused breathing is a relaxation technique, but it is distinct from guided imagery. Guided imagery specifically involves creating vivid mental pictures to distract and soothe the mind.
B. "I'll listen to my favourite music to take my mind off the pain." Listening to music is a form of distraction or music therapy, which can help with pain management but is different from guided imagery, which relies on mental visualization.
C. "I'll think about my grandfather's farm to reduce pain." This statement reflects guided imagery, where the client mentally pictures a peaceful, pleasant scene to divert attention from pain and promote relaxation, showing understanding of the technique.
D. "I'll learn to notice the sensation of muscle tension." Noticing muscle tension is related to mindfulness or biofeedback, focusing on awareness of bodily sensations rather than the visualization involved in guided imagery.
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