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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

followed by .
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  • Place a tongue blade in the client’s mouth: This is unsafe and outdated.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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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 ["A","B","D","E"]

Explanation

A. History of diabetes mellitus: Diabetes causes impaired blood flow and neuropathy, which delay wound healing by reducing oxygen and nutrient delivery to tissues and increasing infection risk.

B. Prealbumin level: A low prealbumin level reflects inadequate protein stores, which are critical for cellular repair, immune function, and the synthesis of collagen during wound healing.

C. Cholesterol level: While elevated cholesterol increases cardiovascular risk, it does not directly affect the biochemical processes involved in wound healing or tissue repair.

D. Mini Nutritional Assessment screening tool score: A low score indicates poor nutritional status, often linked with deficiencies in vitamins, minerals, and protein that are necessary for effective tissue repair and immune response.

E. History of malnutrition: Malnutrition results in diminished energy reserves and nutrient deficiencies, both of which weaken the body's capacity to regenerate tissue and fight infections, prolonging wound healing time.

F. History of hyperlipidemia: Hyperlipidemia contributes to atherosclerosis but is not directly associated with impaired wound healing or immune function necessary for tissue recovery.

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