After placing a client who is having a seizure in the side-lying position, which intervention should the nurse implement?
Apply soft restraints to all extremities.
Remove objects that could cause injury.
Place pillows around the client's head.
Administer oxygen per nasal cannula.
The Correct Answer is B
Choice A reason: Applying soft restraints to all extremities is not appropriate during a seizure as it can increase the risk of injury. The priority is to ensure the client's safety by preventing injury without restraining them.
Choice B reason: Removing objects that could cause injury is crucial. During a seizure, the client may move unpredictably, and any nearby objects could pose a risk of harm. Clearing the area ensures the client has a safe space to have the seizure without additional hazards.
Choice C reason: Placing pillows around the client's head can provide some protection, but it is not as immediately effective or necessary as removing potentially harmful objects from the surrounding area. Ensuring a clear and safe environment is the primary concern.
Choice D reason: Administering oxygen per nasal cannula is not the first priority during a seizure. While maintaining oxygenation is important, the immediate focus should be on ensuring the client's physical safety by removing dangerous objects. Once the seizure subsides, appropriate respiratory support can be provided if needed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Drinking regular colas can lead to fluctuations in blood glucose levels and is not an appropriate recommendation for managing nausea in a client with diabetes.
Choice B reason: Not injecting additional insulin until solid food can be tolerated is not advisable, as it may lead to hyperglycaemia or diabetic ketoacidosis. Insulin needs to be managed carefully even if the client is not eating.
Choice C reason: Going to the emergency room immediately may not be necessary if the client can manage their blood glucose levels at home with proper guidance.
Choice D reason: Monitoring blood glucose levels and drinking fluids as tolerated is the best initial advice. This helps prevent dehydration and maintain glucose control while dealing with the nausea. The client should also follow sick day management guidelines for diabetes and stay in touch with their healthcare provider.
Correct Answer is B
Explanation
Choice A reason: Stool with fatty streaks is not a common finding in ulcerative colitis. It is more associated with malabsorption syndromes.
Choice B reason: Blood in the stool is a significant finding in ulcerative colitis, especially during an acute exacerbation. It indicates active inflammation and potential bleeding in the colon, which requires immediate attention and intervention.
Choice C reason: Clay-coloured stool usually indicates a problem with the bile ducts or liver, such as bile duct obstruction. It is not specific to ulcerative colitis.
Choice D reason: Hard pellets of stool indicate constipation, which is not typically associated with ulcerative colitis, especially during an acute exacerbation where diarrhea is more common.
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