While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

Observe for prolonged periods of apnea.

Observe for lacerations to the tongue.

Document details of the seizure activity.

Evaluate for evidence of incontinence.

Answer and Explanation

The Correct Answer is A

A.   This intervention is important for assessing the client's respiratory status during and after the seizure. Apnea can cause cardiac arrest and respiratory failure and hence a priority.
B.   This intervention is crucial for assessing potential injury to the client's mouth or tongue, which can occur during a seizure due to involuntary muscle movements. However, before assessing for lacerations, the nurse should prioritize ensuring the client's safety.
C.   Documenting details of the seizure activity is important for maintaining accurate medical records and providing information to the healthcare team. However, before documenting details of the seizure, the nurse should prioritize ensuring the client's safety and providing immediate assistance during the seizure. Therefore, while documentation is essential, it may not be the first intervention to implement.
D.   While evaluating for incontinence is important for addressing the client's immediate needs and ensuring comfort, it may not be the first intervention to implement. The nurse should prioritize ensuring the client's safety and providing immediate assistance during the seizure.

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Correct Answer is ["A","B","D","E","F","G"]

Explanation

A. Patients with respiratory distress often prefer to sit upright or in a tripod position to ease breathing by allowing maximal lung expansion. Sitting upright helps relieve pressure on the diaphragm and allows better air exchange in the lungs.
B. Chest tightness is a common symptom of various respiratory conditions, such as asthma, chronic obstructive pulmonary disease (COPD), or pneumonia. It can result from bronchoconstriction, inflammation, or accumulation of mucus in the airways, leading to difficulty breathing.
D. An increased respiratory rate (tachypnea) may indicate respiratory distress or difficulty breathing. Tachypnea is a compensatory mechanism to increase oxygen intake or remove carbon dioxide from the body when lung function is compromised.
E. Restlessness can be a cue for a respiratory problem. Patients experiencing respiratory distress may exhibit restlessness due to hypoxia (low oxygen levels), discomfort, or anxiety related to difficulty breathing.
F. Dyspnea, or shortness of breath, is a significant cue for a respiratory problem. It is a common symptom of various respiratory conditions, including asthma, COPD, pneumonia, and pulmonary embolism. Dyspnea may range from mild to severe and can significantly impact the patient's quality of life and functional status.
G. A pulse oxygenation level of 85% indicates hypoxemia (low blood oxygen levels) and is a significant cue for a respiratory problem. Hypoxemia can result from various respiratory conditions or inadequate ventilation and may lead to tissue hypoxia and organ dysfunction if left untreated.
C. Medication compliance is not directly indicative of a respiratory problem. However, it may be relevant to managing respiratory conditions if the patient requires medications such as bronchodilators or corticosteroids to control symptoms or prevent exacerbations.
H. While an elevated heart rate (tachycardia) can be associated with respiratory distress, it is not specific to respiratory problems and may occur in response to other stressors or medical conditions.
I. Body mass index (BMI) is a measure of body fat based on height and weight and is not directly indicative of a respiratory problem. However, obesity is a risk factor for respiratory conditions such as obstructive sleep apnea and obesity hypoventilation syndrome.

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

Explanation

Option 1-prediabetes

Option 2- impaired glucose tolerance

Rationale

Prediabetes is a condition characterized by higher than normal blood sugar levels, but not high enough to be classified as type 2 diabetes. It's considered a warning sign that indicates an increased risk of developing type 2 diabetes, heart disease, and stroke if left unmanaged.

Prediabetes is diagnosed if FPG levels are between 100-125 mg/dL, OGTT levels are between 140-199 mg/dL, or HbA1c levels are between 5.7-6.4%.

It occurs due to impaired glucose tolerance in insulin resistance. In individuals with insulin resistance, cells, particularly muscle, liver, and fat cells, become less sensitive to insulin's actions. As a result, glucose uptake by cells is impaired, leading to higher blood sugar levels. Hypoglycemia refers to a condition characterized by abnormally low blood sugar levels, typically below 70 mg/dL (3.9 mmol/L). It occurs when there is an imbalance between the amount of glucose in the bloodstream and the body's requirements for energy.

Gestational diabetes mellitus (GDM) is a type of diabetes that develops during pregnancy. It is characterized by high blood sugar levels that occur for the first time during pregnancy and typically resolves after childbirth.

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While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits What finding(s) are cues for a respiratory problem? Select all that apply.

Correct Answer is ["A","B","D","E","F","G"]

Explanation

Patient Data Exhibits Based on the laboratory data, the client has dropdown related to dropdown

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

Explanation

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