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A nurse is caring for a client.

Exhibits

A nurse is reviewing the client's medical record. After reviewing the medical record, which of the following actions should the nurse plan to take?

For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

A.

Encourage the client to cough.

B.

Initiate seizure precautions.

C.

Elevate the head of the bed.

D.

Keep the client's head in a midline position.

E.

Decrease oxygen to 1.5 L/min via nasal cannula.

F.

Assist the client to the bathroom.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"C"}}

Rationale

Interpretation of Actions:

  • Encourage the client to cough:
    • Nonessential
      Encouraging the client to cough is not a priority in this situation. The client's neurological status is deteriorating, and the focus should be on managing intracranial pressure and ensuring airway patency rather than promoting coughing.
  • Initiate seizure precautions:
    • Anticipated
      Seizure precautions are appropriate due to the client's declining neurological status, as seizures can occur with increased intracranial pressure or other neurological changes.
  • Elevate the head of the bed:
    • Anticipated
      Elevating the head of the bed to 30 degrees promotes venous drainage and helps reduce intracranial pressure, which is critical given the client's symptoms.
  • Keep the client's head in a midline position:
    • Anticipated
      Maintaining a midline head position prevents obstruction of venous outflow and helps reduce intracranial pressure.
  • Decrease oxygen to 1.5 L/min via nasal cannula:
    • Contraindicated
      Reducing oxygen is inappropriate in this situation. The client's altered mental status and vomiting suggest potential hypoxia or increased intracranial pressure, requiring close monitoring of oxygenation rather than decreasing it.
  • Assist the client to the bathroom:
    • Contraindicated
      Assisting the client to the bathroom is unsafe due to their altered mental status, restlessness, and risk of falls or further neurological compromise. Instead, measures to prevent overexertion, such as using a bedpan, should be implemented.


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Related Questions

Correct Answer is "{\"xRanges\":[53.828125,93.828125],\"yRanges\":[164,204]}"

Explanation

A. The stoma from a transverse colon resection with colostomy placement is typically located in the right iliac fossa, which is the lower right quadrant of the abdomen. This is where the transverse colon is most often brought to the surface for colostomy placement. It allows for easier access and drainage postoperatively.

B. The epigastric area, which is located above the umbilicus, is not a typical location for a colostomy stoma. This area is more commonly associated with upper abdominal organs such as the stomach and liver.

C. The left iliac fossa is generally where a descending or sigmoid colostomy would be placed, rather than a transverse colon resection. This location would be expected for colostomies created from the descending colon, not the transverse colon.

Correct Answer is B

Explanation

A. Keep the client's bedroom dark at night is not recommended. People with Alzheimer's disease may experience confusion and disorientation, especially during the night. Keeping the room well-lit can help reduce confusion and improve the client's sense of time.

B. Place a large-face clock in the client's bedroom is a helpful strategy. A large clock can help the client orient themselves to the time of day, which can reduce anxiety and confusion. This is an effective way to help clients with Alzheimer's disease maintain a sense of time and structure.

C. Cover electrical outlets in the client's home with tape is not a necessary safety measure for Alzheimer's disease. While safety is important, the primary focus should be on reducing the risk of falls, confusion, and disorientation. Tape on outlets is not a standard safety recommendation for Alzheimer's patients.

D. Hang a monthly calendar in the client's bedroom is a good idea for some clients, but a calendar may not be as immediately helpful as a clock in the bedroom. While a calendar can help orient the client to the date, a clock is more effective for helping them understand the time of day.

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