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A nurse is assisting in the care of a client.

Exhibits

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"}

Rationale for Correct Answers:

  • Turn the client to their side: This is a crucial first action. During a seizure, turning the client to their side (recovery position) helps to maintain an open airway, prevent aspiration of saliva or vomitus, and allow secretions to drain from the mouth.
  • Call for assistance: After ensuring the client's safety and positioning, the nurse should call for help to ensure appropriate and prompt support from the healthcare team.

Rationale for Incorrect Answers:

  • Restrain the client: Restraining a client during a seizure can cause injury. Instead, ensure the area is safe and the client is protected from harm without restricting movement.
  • Place a tongue blade in the client’s mouth: This is unsafe and outdated. Inserting anything in the mouth during a seizure can break teeth or obstruct the airway.
  • Administer lorazepam: Although lorazepam is used to treat ongoing prolonged seizures, it is not the first action in this scenario. Medication administration follows basic safety measures and calling for support.


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Related Questions

Correct Answer is C

Explanation

A. "I'll use focused breathing to control my pain." Focused breathing is a relaxation technique, but it is distinct from guided imagery. Guided imagery specifically involves creating vivid mental pictures to distract and soothe the mind.

B. "I'll listen to my favourite music to take my mind off the pain." Listening to music is a form of distraction or music therapy, which can help with pain management but is different from guided imagery, which relies on mental visualization.

C. "I'll think about my grandfather's farm to reduce pain." This statement reflects guided imagery, where the client mentally pictures a peaceful, pleasant scene to divert attention from pain and promote relaxation, showing understanding of the technique.

D. "I'll learn to notice the sensation of muscle tension." Noticing muscle tension is related to mindfulness or biofeedback, focusing on awareness of bodily sensations rather than the visualization involved in guided imagery.

Correct Answer is B

Explanation

A. Testicular examination: Testicular cancer screening is typically encouraged from adolescence to around age 35, as it is more common in younger men. Routine testicular exams are not specifically recommended starting at age 50.

B. Colonoscopy: Colorectal cancer screening, such as colonoscopy, should begin at age 45 or 50 for individuals at average risk. It is a key preventive measure for detecting colorectal cancer in its early stages.

C. Clinical breast examination: Clinical breast exams may be done earlier, typically starting in the 20s or 30s, depending on risk factors. They are not newly initiated at age 50.

D. Fasting blood glucose: Screening for diabetes may begin as early as age 35 in adults with risk factors. It is important but not specifically recommended as a new screening starting at age 50.

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