A nurse is assisting with the care of a client.

The nurse is collecting data from the client.

Select words from the choices to fill in each blank in the following sentence

The nurse should identify that

____

and

____

Indicate manifestations of borderline personality disorder

A. Insert an oral airway into the client’s mouth:Attempting to insert any object into the mouth during a seizure risks airway obstruction, dental injury, or aspiration of oral secretions or broken teeth. The jaw is typically clenched, making insertion unsafe and impractical.

B. Measure the duration of the seizure:While timing the seizure is important for documentation and determining if status epilepticus occurs, it should not take precedence over immediate physical safety measures. Restraint to prevent injury must occur first.

C. Lower the side rails of the bed when the seizure begins:Lowering the side rails increases the risk of the client falling from the bed. Instead, the bed rails should remain raised and padded (if possible) to create a contained, safe environment.

D. Restrain the client's arms and legs to prevent injury:Gentle but firm restraint of the extremities reduces the risk of the client striking themselves against hard surfaces (e.g., bed rails, walls) or experiencing dislocations, fractures, or self-inflicted trauma. Restraint should be applied cautiously to avoid excessive force, but it is necessary to maintain physical control during the seizure’s intense muscular contractions.

A. Chronic health condition: The client has a history of Parkinson’s disease and anxiety, which are relevant but not immediate concerns. Chronic conditions require long-term management rather than urgent intervention.
B. Current level of consciousness: The client is restless and not following commands, which may indicate hypoxia, worsening infection, or sepsis. A change in mental status is a critical finding requiring immediate evaluation.
C. Oxygen saturation level: The oxygen saturation is 89% on room air, which is below the normal range (≥95%). This suggests respiratory compromise, likely due to pneumonia, requiring urgent oxygen support.
D. Heart rate: The client has a heart rate of 104/min, which is mildly elevated and expected due to fever and respiratory distress. However, it is not the most critical concern compared to respiratory distress and altered mental status.
E. Respiratory rate: The respiratory rate is 30/min, indicating tachypnea and increased work of breathing, suggesting respiratory distress or impending respiratory failure. This requires immediate intervention.
F. Tremors: Tremors are a common finding in Parkinson’s disease and do not require immediate intervention.