The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)

Ensure oral suction is available.

Provide frequent mouth care.

Keep the room at a comfortable temperature.

Maintain the client in a semi-Fowler's position.

Answer and Explanation

The Correct Answer is A

A. Ensuring oral suction is available is the most essential intervention to maintain a clear airway and prevent aspiration during and after seizures, particularly in an unconscious client.

B. Providing frequent mouth care is important for oral hygiene but may not be as critical as ensuring a patent airway during seizures.

C. Keeping the room at a comfortable temperature is important for overall comfort but is not the most essential intervention during seizure activity.

D. Maintaining the client in a semi-Fowler's position may help with ventilation and drainage but is not as crucial as ensuring airway patency.

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Correct Answer is D

Explanation

A. Acute pain related to renal calculus is important and needs to be addressed, but managing potential life-threatening conditions, like aspiration, takes precedence.

B. Nutritional deficit related to nausea is also a concern but is not as urgent as preventing aspiration.

C. Impaired renal function related to pain could be important in the long term, but it does not pose an immediate risk like aspiration does. Therefore, it is not the highest priority.

D. Risk for aspiration related to vomiting is the highest priority because it addresses the immediate potential for airway compromise, which can be life-threatening if the client aspirates vomitus. Ensuring the airway is protected and that aspiration does not occur is critical.

A. Palpitations and shortness of breath. B. Bradycardia and constipation. C. Muscle cramping and dry, flushed skin. D. Lethargy and lack of appetite.

Correct Answer is A

Explanation

A. Palpitations and shortness of breath are symptoms of thyrotoxicosis, indicating excessive thyroid hormone levels, which could result from an overdose of levothyroxine sodium.

B. Bradycardia and constipation are more indicative of hypothyroidism, which would suggest the need for an increase in levothyroxine dosage rather than a decrease.

C. Muscle cramping and dry, flushed skin are symptoms of hypothyroidism, which would suggest inadequate thyroid hormone replacement rather than excess.

D. Lethargy and lack of appetite are also symptoms of hypothyroidism, not hyperthyroidism, which would not typically result from an overdose of levothyroxine.

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The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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