A nurse is assisting in the care of a client.
Complete the following sentence:
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":"D"}
At 1000, when the nurse enters the client's room and the client is experiencing an aura followed by generalized jerking contractions of arms and legs, the first action the nurse should take is to ensure the client's safety. This includes removing any potential hazards from the immediate vicinity, such as pillows that could obstruct the airway or cause suffocation.
The next critical action is to turn the client to their side, which helps maintain an open airway, allows for any secretions to drain, and reduces the risk of aspiration should vomiting occur. These steps are vital in managing a seizure and are part of the standard care procedures to protect the client during and after a seizure episode.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Using overhead lighting can disrupt the client's sleep by increasing stimulation; instead, use minimal lighting during nighttime assessments.
B. Keeping the door to the client's room closed can help reduce noise and disturbances from the hallway, promoting a more conducive sleep environment.
C. Providing snug-fitting nightwear may not directly address the underlying causes of insomnia and might not be effective for all clients.
D. Administering diuretics in the evening may exacerbate nocturia and disrupt sleep patterns; instead, diuretics are typically given earlier in the day to minimize nighttime urination.
Correct Answer is B
Explanation
A. Limiting snacks between meals may further decrease the client's overall food intake, which could exacerbate the risk of malnutrition.
B. Providing the client with finger foods makes eating more manageable for individuals with dementia who may have difficulty using utensils or maintaining attention during meals. This approach encourages independent eating and may increase food intake.
C. Restricting visitors during meals may lead to social isolation and could interfere with the client's enjoyment of mealtime, potentially further reducing food intake.
D. Providing the client with three large meals each day may be overwhelming and may not align with the client's preferences or eating habits. Offering smaller, more frequent meals throughout
the day is often more manageable for individuals with dementia.
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