A nurse is caring for a client.
A nurse is reviewing the client's medical record. After reviewing the medical record, which of the following actions should the nurse plan to take? For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
Assist the client to the bathroom.
Initiate seizure precautions.
Record GCS every 15 min for the first 4 hr.
Elevate the head of the bed
Keep the client's head in midline position
Encourage the client to cough
Decrease oxygen to 1.5L/min via nasal cannula
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"C"}}
Rationale
• Assist the client to the bathroom.
• Non-essential: The client’s current condition indicates severe changes, including a significant drop in consciousness and worsening vital signs. Immediate priorities involve stabilization and monitoring rather than assisting with bathroom needs.
• Initiate seizure precautions.
• Anticipated: The client’s deteriorating condition, including restlessness, agitation, and decreased level of consciousness, increases the risk of seizures. Initiating seizure precautions is appropriate to ensure safety.
• Record GCS every 15 min for the first 4 hr.
• Anticipated: The Glasgow Coma Scale (GCS) score of 9 indicates a significant decrease in consciousness. Frequent monitoring of GCS is crucial to assess changes in neurological status and to guide further intervention.
• Elevate the head of the bed.
• Anticipated: Elevating the head of the bed can help with cerebral perfusion and decrease intracranial pressure. This is a common intervention for clients with neurological issues to improve comfort and safety.
• Keep the client's head in midline position.
• Anticipated: Maintaining a midline position helps ensure optimal cerebral perfusion and reduces the risk of complications. It is particularly important in clients with neurological changes.
• Encourage the client to cough.
• Non-essential: Given the client's current level of consciousness and agitation, encouraging coughing might not be appropriate and could cause further distress or complications.
• Decrease oxygen to 1.5L/min via nasal cannula.
• Contraindicated: The client’s oxygen saturation has dropped to 90% despite receiving 6 L/min of oxygen. Decreasing the oxygen flow could further impair oxygenation. The priority is to maintain or increase oxygen levels to ensure adequate oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Limit physical activity until bladder continence is achieved: Limiting physical activity is not recommended and can impact overall health. Encouraging regular activity may help improve bladder function and overall well-being.
B. Encourage the client to contract the abdominal muscles when they experience the urge to void: Contracting the abdominal muscles is not typically recommended for managing incontinence. The focus should be on bladder training and strengthening the pelvic floor muscles.
C. Instruct the client to void as soon as they feel the urge: This approach may not support bladder training, which aims to increase the time between voids to improve bladder control.
D. Instruct the client to void at scheduled times throughout the day: This is correct as scheduled voiding helps retrain the bladder, gradually increasing the intervals between voids and improving continence.
Correct Answer is B
Explanation
A. Speech therapist: A speech therapist is typically involved in addressing communication and swallowing difficulties, not difficulties with using utensils.
B. Occupational therapist: This is correct as an occupational therapist specializes in helping clients with daily living activities, including fine motor skills and adaptive techniques for using utensils.
C. Physical therapist: Physical therapists focus on improving mobility, strength, and coordination but do not primarily address difficulties with using utensils.
D. Recreational therapist: Recreational therapists focus on leisure activities and hobbies, which are not directly related to the use of utensils for eating.
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