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
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- Place a tongue blade in the client’s mouth: This is unsafe and outdated.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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I will be told about alternative procedures before I'm asked to sign the consent form." Understanding alternative options is a key component of informed consent. Clients must be informed about the risks, benefits, and alternatives to the proposed procedure so they can make a voluntary, educated decision.
B. "My nurse is responsible for obtaining informed consent." While nurses often witness the client’s signature and may provide teaching, the responsibility for obtaining informed consent legally lies with the provider performing the procedure, who must explain the details and answer questions.
C. "Once I sign the consent form, I cannot change my mind about having the procedure." Clients retain the right to withdraw consent at any time before the procedure begins. Signing the form does not waive this right, and they can refuse or delay the procedure if they choose.
D. "The consent form will include the estimated time for my recovery from the procedure." Recovery time is usually discussed during preoperative teaching but is not a required element of the consent form itself. The form primarily covers procedure details, risks, and alternatives.
Correct Answer is A
Explanation
A. Decrease background noise: Reducing ambient noise helps clients with hearing loss focus better on the speaker’s voice, minimizing distractions and enhancing their ability to interpret sounds or speech through residual hearing or lip-reading.
B. Speak in a loud voice: Speaking loudly can distort speech sounds and facial expressions, making it harder for clients to understand. It’s more effective to speak clearly at a moderate pace and volume.
C. Use short phrases: While shorter phrases might seem easier to process, effective communication often depends on clear context and full sentences. Using natural language helps convey meaning more accurately.
D. Talk at a rapid rate: Rapid speech can be difficult for individuals with hearing loss to follow, especially if they rely on lip-reading. Slower, clearer speech improves understanding and facilitates better communication.
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