A nurse is caring for a client in bed and begins experiencing a tonic-clonic seizure.
Which of the following actions should the nurse take?
Insert an oral airway into the client's mouth.
Lower the side rails of the bed when the seizure begins.
Measure the duration of the seizure.
Restrain the client's arms and legs to prevent injury.
The Correct Answer is C
A. Insert an oral airway into the client's mouth. Inserting anything into the client’s mouth during a seizure is contraindicated due to the risk of oral injury, aspiration, or causing airway obstruction.
B. Lower the side rails of the bed when the seizure begins. Lowering the side rails is inappropriate and increases the risk of the client falling out of bed and sustaining an injury. Instead, the nurse should ensure padded side rails are in place or protect the client by cushioning their head and limbs if side rails are not padded.
C. Measure the duration of the seizure. It is critical to measure the duration of a seizure to provide accurate information to the healthcare team. The duration helps determine the severity of the seizure and the need for medical interventions, such as administering medications to stop prolonged seizures (status epilepticus).
D. Restrain the client's arms and legs to prevent injury. Restraint during a seizure is inappropriate and can cause musculoskeletal injuries. The nurse should allow the seizure to run its course while ensuring the client’s safety.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Protein is essential for wound healing as it plays a crucial role in tissue repair and regeneration. It provides the building blocks for new tissue formation and helps in the synthesis of collagen, which is necessary for wound healing. Adequate protein intake promotes wound healing by supporting the growth of new cells, enhancing immune function, and aiding in the formation of new blood vessels.
Calcium is important for bone health but does not directly impact wound healing. However, a balanced diet that includes sources of calcium is generally recommended for overall health. Vitamin D plays a role in bone health and has some influence on immune function and wound healing. However, the primary focus in this scenario should be on protein intake.
Fats, specifically essential fatty acids, are necessary for overall health and immune function. However, increasing fats in the diet may not directly impact wound healing. It is important to consume a balanced diet that includes healthy fats, but the emphasis for wound healing is on protein intake.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}
Explanation
The nurse should identify that emotional dysregulation and fear of abandonment indicate manifestations of borderline personality disorder. Emotional dysregulation is a hallmark of borderline personality disorder (BPD), characterized by intense and rapidly shifting emotions. Fear of abandonment is a core feature of BPD, leading to anxiety and distress over perceived or anticipated rejection by significant others.
A. Tactile hallucinations: Tactile hallucinations refer to false perceptions of touch or physical sensations on the skin, which are not typically associated with borderline personality disorder. These hallucinations are more commonly associated with conditions like schizophrenia or substance-induced disorders.
B. Emotional ability: Emotional dysregulation is a hallmark of borderline personality disorder (BPD). Individuals with BPD often experience intense and rapidly shifting emotions that can be triggered by seemingly minor events. This emotional volatility can lead to difficulties in interpersonal relationships and impulsive behaviors.
C. Fear of abandonment: Fear of abandonment is a core feature of borderline personality disorder. Individuals with BPD often experience intense anxiety and distress when they perceive or anticipate rejection or abandonment by significant others. This fear can drive their behaviors, including efforts to prevent real or imagined abandonment.
D. Elevated body temperature: Elevated body temperature is not a characteristic manifestation of borderline personality disorder. Instead, it may be associated with medical conditions such as infections or inflammatory processes.
E. Increased heart: While emotional distress and anxiety are common in individuals with borderline personality disorder, "increased heart" is not a specific manifestation of the disorder. Anxiety and emotional distress can lead to physiological responses such as increased heart rate, but this is a general response rather than a defining characteristic of BPD.
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