A nurse is preparing to conduct a fall risk screening on a client.
Which of the following variables will the nurse use to evaluate the client? (Select all that apply.)
Fall history.
Medical diagnosis.
Use of assistive devices.
Mental status.
Do-not-resuscitate status.
Correct Answer : A
Choice A rationale:
Maintaining the patency of the client's airway is the priority action. During a seizure, the client may lose consciousness and have difficulty breathing. Ensuring a clear airway is essential to prevent hypoxia and maintain oxygenation. This can be achieved by positioning the client on her side and removing any obstructions from her mouth to allow for adequate airflow.
Choice B rationale:
Identifying the poison the client ingested is important for providing appropriate medical treatment, but it is not the priority action in this scenario. Airway management takes precedence because it addresses the immediate threat to the client's life.
Choice C rationale:
Measuring the client's blood pressure is a necessary assessment, but it is not the priority during an active seizure. Airway management and seizure control are the immediate concerns. Once the seizure is controlled and the airway is secured, other assessments, including blood pressure measurement, can be performed.
Choice D rationale:
Positioning the client on her side is a correct action, but it should be done after ensuring the patency of the airway. Placing the client on her side helps prevent aspiration in case of vomiting during or after the seizure. However, it is not the priority over ensuring the client can breathe properly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A suffix is a word part that is added to the end of a root word to modify its meaning. For example, in the medical term "cardiologist," the suffix '-ologist' means a specialist or expert. A suffix is placed at the end of a root word or a combining form to create a specific medical term.
Choice B rationale:
A word root is the foundational part of a medical term. It contains the core meaning of the term and is not usually modified by prefixes or suffixes. For instance, in the term "cardiology," 'cardi-' is the word root, representing the heart. Word roots provide the essential meaning of the medical term.
Choice C rationale:
A prefix is a word part that is added to the beginning of a root word or a combining form to modify its meaning. Prefixes are important in medical terminology as they indicate locations, numbers, or time. For example, in the term "prehypertension," the prefix 'pre-' means before. Prefixes are added at the beginning of a word.
Choice D rationale:
A combining form is a word root combined with a vowel (usually 'o') that can be joined with other word parts to create a medical term. Combining forms are used as a connector to join a root word and a suffix or another root word. For example, in the term "gastritis," 'gastr-' is the combining form, representing the stomach. Combining forms facilitate the construction of complex medical terms.
Correct Answer is C
Explanation
Choice A rationale:
This option is incorrect. Tachypnea refers to abnormally fast breathing, typically defined as a respiratory rate higher than 20 breaths per minute in adults. It is the opposite of the condition described in the question, where the respiratory rate has fallen below 10 respirations per minute.
Choice B rationale:
This option is incorrect. Apnea refers to the absence of breathing, often resulting from a temporary cessation of airflow to the lungs. It is characterized by the complete absence of respiratory movements and sounds, which is different from the situation described in the question where the client is breathing at a very slow rate.
Choice C rationale:
Bradypnea, or abnormally slow breathing, is the correct answer in this case. It is defined as a respiratory rate lower than the normal range, which is typically between 12 to 20 breaths per minute in adults. Bradypnea can be caused by various factors, including drug overdose, neurological disorders, or metabolic imbalances. In this scenario, the client's slow respiratory rate (below 10 respirations per minute) indicates bradypnea.
Choice D rationale:
This option is incorrect. Eupnea refers to normal breathing, where the rate and depth of respirations are within the normal range. It does not describe the condition of the sedated client in the question, who is experiencing abnormally slow breathing (bradypnea)
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