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A nurse is assisting in the care of a client.

Exhibits

Complete the following sentence:

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":"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 {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

​​​​​​

Provider prescription

Expected

Unexpected

Home health evaluation of home safety

X

Vitamin D supplement 2,500 units daily

X

Vitamin D supplement 2,500 units daily

X

Increase caffeine intake

X

Physical therapy for muscle- strengthening and balance-

training

X

Increase daily sun exposure

X
  • Home health evaluation of home safety: Expected, as it can help prevent falls, which are a significant risk for patients with osteoporosis due to increased fracture risk.
  • Vitamin D supplement 2,500 units daily: Expected, since Vitamin D is essential for calcium absorption and bone health, and supplementation is commonly recommended for osteoporosis patients.
  • Calcium 1500 mg po once daily on an empty stomach: Expected, because adequate calcium intake is crucial for maintaining bone density and overall bone health.
  • Increase caffeine intake: Unexpected, as excessive caffeine can interfere with calcium absorption and exacerbate bone density loss.
  • Physical therapy for muscle-strengthening and balance-training: Expected, to improve muscle strength, balance, and coordination, which can help reduce the risk of falls and subsequent fractures.
  • Increase daily sun exposure: Expected, but with caution. While sun exposure helps with Vitamin D synthesis, it should be balanced with skin cancer risk, especially in older adults.

Correct Answer is D

Explanation

A. Keep legs straight: Keeping the legs straight while lifting can strain the back muscles and increase the risk of injury. Instead, the legs should be bent at the knees to provide better support.
B. Bend at the waist: Bending at the waist can also strain the back muscles and increase the risk of injury. The correct technique is to bend at the knees and hips while keeping the back straight.
C. Hold object away from the body: Holding objects close to the body while lifting can help reduce strain on the back. Holding objects away from the body can increase the risk of injury.
D. Tighten the abdominal muscles: Tightening the abdominal muscles can help stabilize the core and support the back during lifting, reducing the risk of injury.

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