A nurse is assisting in the care of a client.

Complete the following sentence by using the lists of options.

At 1000 the nurse enters the client's room. The first action the nurse should take is
_
followed by
_
.

Answer and Explanation

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

Correct answers: At 1000 the nurse enters the client's room. The first action the nurse should take is call for assistance followed by turn the client to their side.

i. call for assistance: According to the nursing process, once a seizure begins (the ictal phase), the nurse must ensure they have help to manage the client's safety and monitor the event. The nurse should stay with the client but call for another staff member to bring emergency equipment or notify the provider.

ii. turn the client to their side: This is the priority safety intervention during a generalized tonic-clonic seizure. Turning the client to a lateral position helps maintain a patent airway and prevents aspiration of oral secretions or vomitus.

Rationale for incorrect answers:

remove the pillows: While removing pillows can help prevent airway occlusion if the head is hyper-flexed, calling for help and positioning the client on their side are higher priorities in the sequence of emergency management.

reorient the client: This occurs during the postictal phase (after the seizure has ended) when the client is regaining consciousness, not during the active seizure at 1000.

administer anticonvulsant medications: While medications like IV lorazepam may be indicated if a seizure is prolonged (status epilepticus), the immediate physical safety and airway management are the first nursing actions.

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Correct Answer is C

Explanation

A. Turn on loud music in client care areas.: Loud noise is a significant environmental stressor that can increase anxiety and disrupt sleep.

B. Assign different nurses to provide care for clients each day.: Constant changes in staff prevent the development of a therapeutic relationship and can increase a client's confusion or stress.

C. Restrict the number of visitors for clients.: Managing the environment by limiting visitors can prevent sensory overload and ensure the client has adequate time for rest and recovery.

D. Offer the clients many choices regarding care.: While autonomy is good, offering "many" choices to a client in acute distress can be overwhelming and increase stress (decision fatigue).

A. Decreased edema formation B. Increased tissue metabolism C. Improved blood flow D. Reduced blood coagulation

Correct Answer is A

Explanation

A. Decreased edema formation: Cold causes vasoconstriction, which reduces capillary permeability and decreases fluid leakage into tissues (edema).

B. Increased tissue metabolism: Cold therapy decreases tissue metabolism and oxygen demand.

C. Improved blood flow: Cold therapy reduces blood flow through vasoconstriction.

D. Reduced blood coagulation: Cold can actually increase blood viscosity and does not therapeutically "reduce" coagulation in this context.

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A nurse is assisting in the care of a client. Complete the following sentence by using the lists of options. At 1000 the nurse enters the client's room. The first action the nurse should take is _____ followed by _____ .

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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A nurse is assisting in the care of a client.

Complete the following sentence by using the lists of options.

At 1000 the nurse enters the client's room. The first action the nurse should take is
_
followed by
_
.