A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure.
Which of the following actions should the nurse take?
- 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.
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.
Insert an oral airway into the client's mouth.
The Correct Answer is B
Lowering the side rails of the bed could lead to the client falling from the bed. Instead raise the side rails and place padding on them.
Measuring the seizure duration is a crucial step for medical evaluation afterwards necessary for determining intervention.
Inserting an oral airway into the client's mouth is not indicated during a tonic-clonic seizure. It is generally not recommended to place any objects or devices into the mouth of a person having a seizure, as it can potentially cause injury to the person or damage to the airway.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
explanation:
Adult day care facilities provide a safe and supervised environment for older adults during the day, while their family members or caregivers are at work or unable to be present. These facilities offer various activities, social interactions, and personal care services to support the needs of individuals with dementia and other conditions. Attending an adult day care facility canalso give the client an opportunity to engage with others and maintain cognitive and physical stimulation.
A- Hospice care is generally recommended for individuals with terminal illnesses who are nearing the end of life. It focuses on providing comfort and support to the patient and family during the end-of-life journey.
B- Long-term care facilities may be appropriate for some individuals with advanced dementia who require round-the-clock care and supervision. However, in this scenario, the client's adult child is present and working full time, suggesting that the family intends to provide care at home as much as possible.
D- Community senior centers may offer various activities and programs for older adults, but they may not provide the level of supervision and care required for an individual with early onset dementia during the day, especially if their family member is at work.
Correct Answer is D
Explanation
Explanation:
Chronic fatigue is a common symptom experienced by clients with leukemia due to various factors, including the disease process, treatment side effects, and anemia. Encouraging strength- training exercises can be beneficial in managing fatigue in these clients. Engaging in regular physical activity, especially strength-training exercises, has been shown to improve muscle strength, endurance, and overall energy levels.
Strength-training exercises help build muscle mass and improve cardiovascular fitness, which can combat fatigue and enhance the client's ability to perform activities of daily living. However, it is essential to individualize the exercise plan based on the client's current physical abilities and energy levels. The nurse should work closely with the client and, if available, a physical therapist or exercise specialist to develop a safe and appropriate exercise program.
Let's briefly discuss the other options:
A- Increase protein in the diet: While a balanced diet that includes an adequate amount of protein is essential for overall health, increasing protein alone may not directly address the issue of chronic fatigue in leukemia clients. While adequate nutrition is important, simply increasing protein intake is not the most effective intervention for managing fatigue in this context.
B- Increase the client's fluids to 4 L per day: Adequate hydration is essential for overall health, but there is no evidence to suggest that increasing fluids alone will directly alleviate chronic fatigue in leukemia clients. The nurse should encourage adequate hydration based on the client's individual needs but should also consider other interventions to address fatigue.
C- Encourage the client to have continual bed rest: Although rest and sleep are important for individuals with leukemia to manage fatigue, promoting continual bed rest can lead to deconditioning and further exacerbate fatigue. Encouraging a balance between rest and physical activity is crucial to managing fatigue effectively.
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