The nurse is caring for a client who is having an active seizure. Which of the following actions should the nurse take? Select all that apply.

Place the client in the recovery position if possible.

Document the start and stop time of the seizure

Hold arms at the client's side to prevent thrashing or injury.

Remove any dangerous objects near the client.

Assist the client to the floor.

Answer and Explanation

Correct Answer : A,B,D,E

A. Place the client in the recovery position if possible. If the client is not actively seizing, placing them in the recovery position (on their side) can help prevent aspiration and allow for better airway management after the seizure ends. However, during the seizure, ensure their safety first.
B. Document the start and stop time of the seizure. It is important to document the timing of the seizure to help assess its duration and determine the appropriate interventions. This also helps guide treatment decisions post-seizure.
C. Hold arms at the client's side to prevent thrashing or injury. The nurse should not restrain the client during a seizure. Trying to hold the client’s arms or restrict their movements can cause injury. The goal is to ensure safety and prevent injury, but not to restrain them.
D. Remove any dangerous objects near the client. Clearing the area of any hard or sharp objects can prevent injury to the client during the seizure.
E. Assist the client to the floor. If the client is standing or sitting during the onset of the seizure, assist them to the floor gently to prevent injury from falling. Ensure that the area is clear of hazards.

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Correct Answer is A

Explanation

A. It is important for the client with diabetes to continue taking their insulin as prescribed, even if they are unable to eat. When the body is under stress (e.g., due to illness), blood sugar levels can rise, and insulin is still necessary to manage glucose levels. Skipping insulin could lead to hyperglycemia or diabetic ketoacidosis (DKA), which can be life-threatening. The nurse should encourage the client to continue insulin therapy and consider alternative ways to manage nausea (e.g., antiemetics).
B. While it is important for the client to monitor their blood glucose, checking it twice a day may not be sufficient during illness. The client should check their blood glucose more frequently (e.g., every 4 hours) to avoid the risk of hyperglycemia or DKA, especially if they are not eating or drinking regularly.
C. When a person with diabetes is ill and unable to eat, it is important to ensure they stay hydrated and maintain glucose levels. Clear liquids such as soda or fruit juice may help with hydration and provide a quick source of sugar if the blood glucose drops too low, though they should be consumed in moderation.
D. It is essential for the client to stay hydrated, especially if they are vomiting. Dehydration can worsen blood sugar control and lead to further complications. The client should be encouraged to drink small, frequent sips of water or electrolyte solutions to stay hydrated.

A. "I will be put to sleep during this procedure." B. "The doctor will be able to remove the cancer through the needle." C. "After the biopsy I will know for sure if I have cancer and what stage it is." D. "The doctor will make a small incision and remove a piece of the tumor."

Correct Answer is D

Explanation

A. A needle biopsy of the thyroid is typically done under local anesthesia, not general anesthesia. The client would be awake during the procedure, although they may be given a sedative to help them relax.
B. A needle biopsy is used to obtain a sample of tissue for testing, not to remove the cancer. The procedure helps diagnose the presence of cancer, but further treatment like surgery would be necessary to remove any cancer.
C. While a needle biopsy can confirm the presence of cancer, it does not provide information about the stage of cancer. Additional imaging and tests would be required to determine the stage.
D. Although the procedure typically involves inserting a needle through the skin (often without making a large incision), the biopsy involves removing a small sample of tissue for examination. This is the correct understanding of a needle biopsy.

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The nurse is caring for a client who is having an active seizure. Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home health nurse is visiting a client with diabetes mellitus, type 2 who reports nausea and vomiting for the past 3 days and not taking prescribed insulin because of the inability to "keep food down." Which of the following responses would be most appropriate for the nurse to make?

Correct Answer is A

Explanation

The nurse has taught a client about a needle biopsy procedure, of the thyroid gland, to diagnose thyroid cancer. Which of the following statements by the client would indicate the teaching was successful?

Correct Answer is D

Explanation

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