A client on alcohol withdraw protocol suddenly begins to have a seizure in his bed. After several minutes the seizure has not ended and the nurse suspects the client is suffering from status epilepticus. What is the priority action the nurse will take?
administer IV lorazepam
lower the client to the floor
allow the client to seize for up to 10 minutes
call a code
The Correct Answer is A
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale; When a client requests pain medication, the first action the nurse should take is to assess the client's current pain level. By using a pain scale, the nurse can determine the intensity of the pain and evaluate the need for pain medication appropriately. The pain scale allows the client to express their pain on a standardized scale, helping the nurse to understand the severity of the pain and the most appropriate pain management intervention.
Choice B rationale: While diversional thoughts and non-pharmacological pain management techniques can be useful, the priority is to first assess the pain level and address the client's immediate needs for pain relief.
Choice C rationale: While it's important to consider the client's history of drug use, it is not the first action to take when a client requests pain medication. Assessing the pain level and providing appropriate pain relief should be the initial priority.
Choice D rationale: While it's essential to know the last dose of pain medication the client received, it is not the first action to take when the client is requesting pain medication. Assessing the current pain level and addressing the client's immediate needs should be the first step. The information about the last dose will be relevant for deciding when the next dose can be given.
Correct Answer is A
Explanation
Choice A rationale: Heartburn when lying down after dinner can be a symptom of gastroesophageal reflux disease (GERD), which is a common concern in individuals with heart failure. Antacids are commonly used to relieve heartburn by neutralizing stomach acid. For patients with heart failure, it is essential to use low sodium antacids because excess sodium intake can worsen fluid retention and lead to increased heart failure symptoms. Low sodium antacids are specifically designed to minimize the sodium content, making them a suitable choice for individuals with heart failure.
Choice B rationale: Diphenhydramine is an antihistamine commonly used for allergy relief and as a sleep aid due to its sedative effects. However, it is not an appropriate choice for relieving heartburn. Diphenhydramine does not have any direct effect on stomach acid, and it is not indicated for GERD or heartburn relief.
Choice C rationale: Low dose aspirin is primarily used as an antiplatelet agent to reduce the risk of blood clots and is commonly prescribed for patients with certain cardiovascular conditions. However, it is not a suitable medication for relieving heartburn. In fact, aspirin can irritate the stomach lining and worsen symptoms of heartburn and gastric irritation.
Choice D rationale: Acetaminophen is a common over-the-counter pain reliever and fever reducer. While it is useful for managing pain and fever, it does not have any effect on stomach acid and is not indicated for heartburn relief. Acetaminophen is not an appropriate choice for addressing heartburn symptoms.
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