The nurse is caring for a client with a terminal illness who has become pulseless. The code status for the client is unknown to the nurse and a hospital emergency response is called. Which of the following actions should the nurse take?
Verify the client's code status.
Begin cardiopulmonary resuscitation.
Provide comfort measures until family arrives.
Initiate a slow code response.
The Correct Answer is B
A. Verify the client's code status: Although verifying code status is important, it may delay necessary emergency interventions. In an urgent situation where the code status is unknown, immediate action is required.
B. Begin cardiopulmonary resuscitation (CPR). When a client is pulseless and the code status is unknown, the priority is to start CPR while emergency services are called. This ensures that the client receives potentially life-saving care promptly.
C. Provide comfort measures until family arrives. This is not appropriate if the client is pulseless and immediate resuscitation efforts are needed.
D. Initiate a slow code response. A slow code is not appropriate in an emergency situation where the patient requires immediate resuscitation.
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Related Questions
Correct Answer is D
Explanation
A. Hemiparesis: Hemiparesis refers to weakness on one side of the body, which does not fully describe the inability to move only the legs.
B. Hypertonicity: Hypertonicity refers to increased muscle tone or stiffness, not the inability to move legs.
C. Crepitation: Crepitation refers to a crackling or popping sound in the joints, not the inability to move legs.
D. Paraplegia: Paraplegia refers to the paralysis of the lower half of the body, including the legs, which fits the description of the patient’s condition.
Correct Answer is C
Explanation
A. "I can provide resistance bands for you to use while performing range-of-motion exercises." Resistance bands are typically used for strengthening exercises, not specifically for isometric exercises.
B. “I want you to walk the hallways twice per day to increase your endurance." Walking is an aerobic exercise and does not represent isometric exercises, which involve static muscle contraction without movement.
C. “I can provide some simple yoga poses for you to practice as this will increase muscle mass." Yoga poses often involve holding positions that engage muscles without movement, which is characteristic of isometric exercises.
D. “Physical therapy will perform passive-range-of-motion with you each day." Passive-range-of-motion exercises are not isometric exercises, as they involve movement of the joints rather than muscle contraction without movement.
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