The nurse observes a client who begins to exhibit continuous jerking movements, is unable to speak, and is incontinent of urine during the event. Which action is most important for the nurse to take?

Place protective padding between the client and bed rails.

Provide privacy for the client during the event.

Observe the client's behavior during the event.

Record the client's level of consciousness after the event.

Answer and Explanation

The Correct Answer is A

A.   Placing protective padding between the client and bed rails is a safety measure to prevent injury during a seizure. This action helps protect the client from head or body trauma if they hit the bed rails or any surrounding surfaces during the seizure.
B.   Providing privacy is important for maintaining the client’s dignity during a seizure, but it is not the most immediate concern. The primary focus during a seizure should be on ensuring the client’s safety and monitoring the event. Privacy can be considered once the immediate safety and medical needs are addressed.
C.   Observing the client's behavior during the seizure is essential for documentation and subsequent medical evaluation. It helps in identifying the type, duration, and characteristics of the seizure, which is crucial for diagnosis and treatment. However, observation alone does not address immediate safety needs or interventions required during the seizure.
D.   Recording the client's level of consciousness after the seizure is important for assessing the postictal state and the extent of recovery. This information is valuable for understanding the impact of the seizure and guiding further medical care. However, during the seizure, immediate actions should focus on ensuring safety and managing the seizure itself.

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Correct Answer is A

Explanation

A. Vital signs are critical for assessing the client’s current hemodynamic status. Coffee-ground emesis can indicate gastrointestinal bleeding, which might lead to complications like hypovolemia or shock.

Vital signs can provide essential information about the client’s condition and help determine the urgency of intervention. Checking vital signs is a priority in assessing the severity of the situation and guiding further actions.
B. Measuring abdominal girth is useful in assessing for abdominal distention or fluid accumulation, which can be relevant in some gastrointestinal conditions. However, in the immediate context of coffee- ground emesis, the most urgent concern is evaluating the client's hemodynamic stability rather than focusing on abdominal girth.
C. Flushing of the skin might be relevant in certain contexts (e.g., reactions to medications or infections), but it is not directly related to the immediate concern of gastrointestinal bleeding and the client’s hemodynamic status. It is less critical compared to assessing vital signs in this situation.
D. While auscultating breath sounds is important for evaluating respiratory status and detecting any pulmonary complications, it is not the immediate priority in the context of coffee-ground emesis. The primary concern should be assessing for signs of hemodynamic instability that may result from gastrointestinal bleeding.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

Based on the information collected, the client is likely experiencing Hypoxia related to Tonic clonic seizure

Rationale

The severe drop in oxygen saturation and the observation of violent jerking movements are consistent with a tonic-clonic seizure, which can be precipitated or exacerbated by significant hypoxia.

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The nurse observes a client who begins to exhibit continuous jerking movements, is unable to speak, and is incontinent of urine during the event. Which action is most important for the nurse to take?

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Naxlex Comprehensive Predictor Exams

After being transferred from the emergency department to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. Which assessment should the nurse complete first?

Correct Answer is A

Explanation

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

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