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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason: Drinking several bottles of carbonated water daily is not a well-established risk factor for renal calculi. While hydration is important in preventing kidney stones, carbonation itself does not significantly increase the risk.

Choice B reason: Eating a vegetarian diet with cheese 2 to 3 times a day can increase the risk for kidney stones, especially if the cheese is high in calcium or oxalates. Dairy products, including cheese, contain calcium, and excessive consumption can contribute to the formation of calcium oxalate stones, which are the most common type of kidney stones.

Choice C reason: Experiencing additional stress since adopting a child is not directly related to the formation of kidney stones. Stress can have various health impacts, but it is not a known primary risk factor for renal calculi.

Choice D reason: Jogging more frequently than the usual daily routine is not associated with an increased risk of kidney stones. Regular physical activity is generally beneficial for overall health and does not contribute to the formation of renal calculi.

A. Peripheral pulses. B. Vital signs. C. Presence of goitre. D. Emotional status.

Correct Answer is B

Explanation

Choice A reason: Assessing peripheral pulses is important for understanding the client's overall circulatory status, but it is not the most urgent assessment in this situation. The client's symptoms suggest a possible thyrotoxic crisis, which requires immediate evaluation of critical vital signs.

Choice B reason: Obtaining vital signs is the most important initial assessment. The client's report of anxiety, heart racing, and pounding could indicate a severe exacerbation of hyperthyroidism, potentially leading to a thyrotoxic crisis (thyroid storm). Vital signs will provide essential information on the client's heart rate, blood pressure, temperature, and overall stability, which are crucial for immediate management.

Choice C reason: The presence of a goitre can indicates thyroid gland enlargement, which is relevant for long-term management of hyperthyroidism. However, it does not provide immediate information on the client's current acute condition.

Choice D reason: Assessing emotional status is important for comprehensive care, but it is not the priority in this acute scenario. The client's physiological status needs to be stabilized first, as indicated by their vital signs, before focusing on their emotional state.

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After placing a client who is having a seizure in the side-lying position, which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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