A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room?
Oral suction equipment
Tongue depressor
Tracheostomy tray
Wrist restraints
The Correct Answer is A
A. Oral suction equipment is correct. During a seizure, there is a risk of aspiration due to the loss of airway control. Oral suction equipment should be readily available in the room to clear the airway if needed, especially if the client experiences a seizure with oral secretions.
B. Tongue depressor is incorrect. A tongue depressor should never be used during a seizure. Inserting a tongue depressor into the mouth can result in injury to both the client and the caregiver and should be avoided.
C. Tracheostomy tray is incorrect. While a tracheostomy tray might be necessary for clients with tracheostomies, it is not a standard requirement for clients on seizure precautions unless the client has specific respiratory concerns or requires a tracheostomy for airway management.
D. Wrist restraints is incorrect. Wrist restraints are not recommended during a seizure, as they can cause injury and impede movement. Instead, the goal is to provide a safe environment to prevent injury during a seizure.
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Related Questions
Correct Answer is D
Explanation
A. Respiratory acidosis is incorrect. Chronic diarrhea typically leads to metabolic acidosis, not respiratory acidosis. Metabolic acidosis occurs due to the loss of bicarbonate through diarrhea, which affects the body’s acid-base balance.
B. Hypermagnesemia is incorrect. Chronic diarrhea is more likely to lead to hypomagnesemia due to the loss of electrolytes through frequent bowel movements, not an increase in magnesium levels.
C. Hypertension is incorrect. Chronic diarrhea generally leads to dehydration and hypotension due to fluid loss rather than high blood pressure.
D. Hypokalemia is correct. Chronic diarrhea causes significant potassium loss, which can result in hypokalemia (low potassium levels). Potassium is lost in the stool, and this depletion can lead to muscle weakness, arrhythmias, and other complications.
Correct Answer is A
Explanation
A. "It is your choice to share personal information during group therapy" is correct. The ethical principle of autonomy emphasizes respecting a client's right to make decisions about their own care, including the right to share or withhold personal information. Allowing the client to choose what to share supports their independence and decision-making ability.
B. "I will be truthful when answering questions about your treatment" promotes veracity, not autonomy. While truthfulness is important in nursing, it does not directly pertain to the principle of client autonomy.
C. "The nursing staff here will provide you with nonjudgmental care" promotes beneficence and respect for the client's dignity, but it does not directly address the principle of autonomy, which focuses on the client’s ability to make choices.
D. "I will only discuss your medical information with the health care team" supports confidentiality and privacy, not autonomy. Autonomy involves respecting a client’s decision-making, not just protecting their information.
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