Share This Link

Performing a neurologic check is important after the seizure has ended, but the immediate action is to protect the client during the seizure.

Notifying the rapid response team is important if the seizure is prolonged or if the client is unresponsive to interventions, but the priority is to ensure safety during the seizure.

Obtaining vital signs can be done after the seizure ends, but the immediate priority is ensuring the client's safety and airway.

Pedal edema is more commonly associated with right-sided heart failure due to fluid retention in the lower extremities.

Neck vein distention is a hallmark of right-sided heart failure, not left-sided heart failure. It occurs due to increased venous pressure.

An enlarged liver is more commonly seen in right-sided heart failure due to congestion of the liver, but it is not a typical manifestation of left-sided heart failure.

While a family member may assist in communication, it is not the most appropriate or professional option, especially if the family member may not be trained to provide accurate information or may not be fluent in sign language.

A board with colored pictures could be useful in some situations, but it is not the most effective or respectful way to communicate with a client who uses sign language.

Familiarizing oneself with commonly used sign language is helpful for general communication, but it is not sufficient for ensuring effective and accurate communication in a healthcare setting.

While the bandage may provide some support to the surgical site, its primary purpose is not to keep sutures from loosening.

The bandage does not directly prevent wound infection; its main role is to manage edema and provide compression. Infection prevention is achieved through sterile technique and wound care.

The bandage does not prevent the client from seeing the surgical site; in fact, it is typically used for compression and edema management.

Decreased urinary output is not a desired effect of morphine. While morphine can cause fluid retention, it is not a primary indication of the medication’s effectiveness in treating acute heart failure.

Emesis (vomiting) is not a typical or intended effect of morphine. It could be a side effect, but it does not indicate that the medication was effective.

An increased respiratory rate would not be an expected or desired effect of morphine. Morphine can depress the respiratory system, so an increased respiratory rate is not an indication that the medication is working as intended.

Diplopia (double vision) is not a typical manifestation of malnutrition. While malnutrition can affect vision in extreme cases, diplopia is more often associated with neurological or other systemic conditions.

Oily skin is not typically associated with malnutrition. In fact, malnutrition often leads to dry, flaky skin due to deficiencies in essential fatty acids and other nutrients.

Increased salivation is not a typical manifestation of malnutrition. It may occur in some specific conditions, but it is not commonly linked to malnutrition.

Shellfish allergies are not typically associated with latex allergies. While both are allergic reactions, they do not share a common mechanism of cross-reactivity.

Eggs are not commonly linked to latex allergies. Although some individuals may have multiple allergies, there is no well-established connection between egg allergies and latex allergies.

Strawberries are not associated with latex allergies. There is no known cross-reactivity between strawberry allergies and latex.

The PPD test is typically evaluated 48 to 72 hours after administration, so returning in another 48 hours is not necessary at this point.

The frequency of PPD testing depends on the individual's risk factors and exposure to tuberculosis (TB), not necessarily on an annual basis.

The test does not need to be repeated at this time. A 12 mm induration is a positive result for individuals with certain risk factors, and further evaluation is needed rather than repeating the test.

While IV fluids are important to prevent renal failure due to myoglobin release, the priority action is to assess for any immediate life-threatening issues, such as cardiac arrhythmias, which are common after electrical shock.

Changing dressings is important for wound care, but it is not the priority action. The client’s immediate survival depends on monitoring and stabilizing the heart.

Administering pain medication is important for comfort but should not be the first priority. The focus should be on stabilizing the client and addressing any immediate life-threatening issues.

Hospice services are appropriate for end-of-life care, but the client with moderate Alzheimer's disease is not at the end of life, so this is not the most appropriate recommendation at this stage.

Pursuing local protective services is necessary if there is evidence of abuse or neglect. However, the issue here seems to be caregiver stress, not abuse, so this action is not warranted.

Taking a nonprescription sleeping medication might address some symptoms of fatigue but does not address the underlying issue of caregiver burnout. Respite care is a more effective solution for the caregiver's needs.