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. Avoiding tight-fitting clothes can help reduce intra-abdominal pressure, which may contribute to GERD symptoms, but it is not the most crucial instruction.

B. Minimizing intake of spicy foods can help decrease gastric irritation and reflux symptoms, but it is not the most important instruction.

C. Beginning a smoking cessation program is important for overall health and may help reduce GERD symptoms, but it is not the most critical instruction for managing GERD.

D. Remaining upright following meals is essential to prevent gastric reflux by reducing pressure on the lower esophageal sphincter. This instruction helps minimize reflux episodes and should be emphasized to the client with GERD.

A. Obtain a keyboard designed to limit wrist flexion. B. Use a space heater to keep the workspace warm. C. Take a multivitamin that contains vitamin D daily. D. Keep both hands elevated during work breaks.

Correct Answer is B

Explanation

A. Obtaining a keyboard designed to limit wrist flexion can help minimize exacerbation of symptoms associated with carpal tunnel syndrome and not Raynaud’s phenomena.

B. Maintaining warmth is crucial for individuals with Raynaud's phenomenon because it helps prevent the onset of symptoms triggered by cold exposure or stress.Keeping the body warm, especially the extremities, helps in minimizing these vasospastic attacks by ensuring that the blood vessels remain dilated, allowing for proper blood flow.

C. While adequate vitamin D intake is important for overall health, it is not specifically indicated as a management strategy for Raynaud's syndrome.

D. Keeping both hands elevated during work breaks may provide some relief, but it may not be practical or feasible for a data entry clerk to maintain this position consistently during work hours.

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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

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

Correct Answer is D

Explanation

A client who works as a data entry clerk is concerned as to how a recent diagnosis of Raynaud's syndrome is going to affect the client's job performance. Which instruction should the nurse provide this client?

Correct Answer is B

Explanation

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