A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?

Loosen the client's clothing.

Help the client lie on the floor.

Turn the client onto their side.

Move items in the room away from the client.

Answer and Explanation

The Correct Answer is B

A. Loosen the client's clothing:
While ensuring a patent airway is essential, it is not the immediate priority when the client is actively seizing. The primary concern is preventing injury by helping the client lie on the floor.
B. Help the client lie on the floor:
This is the correct answer. When a client is having a seizure, the priority is to ensure their safety. Lying the client on the floor helps prevent injury during the seizure, reducing the risk of falling from a chair or bed. Placing the client in a lateral (side) position can also help maintain an open airway.
C. Turn the client onto their side:
This action is part of the process after helping the client lie on the floor. Turning the client onto their side helps prevent aspiration in case of vomiting and maintains an open airway.
D. Move items in the room away from the client:
While creating a safe environment by moving objects away is important, the immediate priority is to prevent injury to the client. Helping the client lie on the floor takes precedence to minimize the risk of injury during the seizure.

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Correct Answer is B

Explanation

A. Respiratory rate:

Respiratory rate is not part of an anthropometric assessment. Anthropometry primarily focuses on physical measurements related to body size, composition, and proportions.

B. Weight:

Anthropometric assessment involves the measurement of various body dimensions, and weight is a

changes over time, and contribute to the overall understanding of a client's health and well-being.

C. Current pain level:

Pain level is not typically included in an anthropometric assessment. Anthropometry is more concerned with physical measurements and does not directly assess subjective experiences like pain.

D. Level of orientation:

Level of orientation is not a component of an anthropometric assessment. Anthropometry is concerned with objective physical measurements and does not assess cognitive or perceptual factors.

A. Assist the client with a bowel cleansing. B. Ensure the client is free of metal objects. C. Monitor the client for pain in the suprapubic region. D. Administer 240 mL. (8 oz) of oral contrast before the procedure

Correct Answer is A

Explanation

A. Assist the client with a bowel cleansing.A bowel cleansing is necessary before an intravenous pyelogram (IVP) to ensure the urinary tract is clearly visualized on the X-ray images. Residual stool or gas in the intestines can obscure the view of the kidneys, ureters, and bladder.

B.Ensure the client is free of metal objects.While ensuring the client is free of metal objects is critical for procedures involving magnetic resonance imaging (MRI) or X-rays of the skeletal system, it is not specifically required for an IVP.

C.Monitor the client for pain in the suprapubic region.Monitoring for suprapubic pain is more relevant after procedures such as catheterization or bladder studies, or in cases of suspected urinary retention or infection.

D.Administer 240 mL (8 oz) of oral contrast before the procedure.An IVP involves injecting contrast dye intravenously, not orally. Oral contrast is typically used for gastrointestinal studies, such as a CT scan of the abdomen or barium swallow.

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A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform an anthropometric assessment on a client. Which of the following client data should the nurse include?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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