A nurse is assisting in the care of a client. Nurses' Notes 2000:

Client presents to emergency department and states, "I have been assaulted." Client was immediately placed in a treatment room.

2015:

"Client states they were out with friends this evening and had "a little too much to drink." Client states that they fell asleep at their friend's house and when they woke up all of their clothes were off and their genitals were sore. The client states, "I think someone had sex with me, but I don't remember anything." Client reports history of depression. Client is a full-time college student who lives with roommates. Client admits to drinking socially but denies illicit drug use and tobacco use.

Which of the following interventions should the nurse plan to implement?

Select all that apply.

Explanation

C. Position the client on their left side

The symptoms of feeling dizzy, racing heart, and becoming pale while lying on their back are consistent with supine hypotensive syndrome or vena cava syndrome. This condition occurs when the pregnant uterus compresses the vena cava, reducing blood flow back to the heart and causing a drop-in blood pressure.

Positioning the client on their left side helps alleviate the pressure on the vena cava, allowing for improved blood flow and preventing further symptoms. This position optimizes blood circulation and reduces the risk of complications. The nurse should assist the client in turning onto their left side and ensure they are comfortable.

Providing the client with a glass of orange juice (option A) is not recommended as it may be helpful in cases of low blood sugar or hypoglycemia, but it is not the most appropriate action in this scenario.

Instructing the client to take a brisk walk (option B) is not recommended since physical exertion can further worsen the symptoms and increase the risk of complications.

Checking the client's temperature (option D) is not necessary as the reported symptoms are not indicative of a fever or infection.

Therefore, the most appropriate action for the nurse to take in this situation is to position the client on their left side (option C).

Correct answer: C

A.Opening the dampers of fireplaces: This instruction is not appropriate during an outdoor chemical disaster. Opening the dampers of fireplaces can allow contaminated air from outside to enter the home, increasing the exposure to hazardous substances. It is best to avoid introducing outdoor air into the home during such incidents.

B. Turning on ceiling fans and air conditioners: This instruction is also not recommended during an outdoor chemical disaster. Turning on fans and air conditioners can potentially circulate contaminated air within the home, leading to increased exposure. It is best to turn off fans and air conditioners during such incidents and focus on evacuating the area.

C. Covering heat registers with plastic and tape: Covering heat registers with plastic and tape would help seal off potential entry points for contaminated air, reducing the risk of indoor contamination.

D.In the case of a nearby outdoor chemical disaster, it is usually safer to stay indoors and seal the home rather than exit, as going outside could increase exposure to the harmful chemicals.