A nurse is assisting in the care of a client.
Complete the following sentence:
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":"D"}
At 1000, when the nurse enters the client's room and the client is experiencing an aura followed by generalized jerking contractions of arms and legs, the first action the nurse should take is to ensure the client's safety. This includes removing any potential hazards from the immediate vicinity, such as pillows that could obstruct the airway or cause suffocation.
The next critical action is to turn the client to their side, which helps maintain an open airway, allows for any secretions to drain, and reduces the risk of aspiration should vomiting occur. These steps are vital in managing a seizure and are part of the standard care procedures to protect the client during and after a seizure episode.
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Related Questions
Correct Answer is C
Explanation
A. While organ donation may be included in advance directives, it is not the primary purpose of advance directives, which are primarily focused on healthcare decision-making.
B. Advance directives do not require approval from an attorney to be enforced. They are legal documents that become effective once signed by the individual, witness, and, in some cases, notarized.
C. This statement indicates an understanding of the procedural requirement for signing a living will, which typically involves witnesses to ensure its validity.
D. Naming a designee in a durable power of attorney for health care is another aspect of advance directives, but this statement does not address the procedural requirements for signing the
document.
Correct Answer is A
Explanation
A. This response acknowledges the client's concerns and opens the conversation for the nurse to address the client's specific needs and preferences, which is crucial in end-of-life care.
B. While pain management is important, addressing the client's concerns about the end-of-life care and their expectations should be the priority.
C. While family visits are significant, addressing the client's immediate concerns about their care takes precedence.
D. Spiritual support is important but may not address the client's immediate concerns about the care they will receive as death approaches.
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