The nurse observes a client who begins to exhibit continuous jerking movements, is unable to speak, and is incontinent of urine during the event. Which action is most important for the nurse to take?

Place protective padding between the client and bed rails.

Provide privacy for the client during the event.

Observe the client's behavior during the event.

Record the client's level of consciousness after the event.

Answer and Explanation

The Correct Answer is A

A.   Placing protective padding between the client and bed rails is a safety measure to prevent injury during a seizure. This action helps protect the client from head or body trauma if they hit the bed rails or any surrounding surfaces during the seizure.
B.   Providing privacy is important for maintaining the client’s dignity during a seizure, but it is not the most immediate concern. The primary focus during a seizure should be on ensuring the client’s safety and monitoring the event. Privacy can be considered once the immediate safety and medical needs are addressed.
C.   Observing the client's behavior during the seizure is essential for documentation and subsequent medical evaluation. It helps in identifying the type, duration, and characteristics of the seizure, which is crucial for diagnosis and treatment. However, observation alone does not address immediate safety needs or interventions required during the seizure.
D.   Recording the client's level of consciousness after the seizure is important for assessing the postictal state and the extent of recovery. This information is valuable for understanding the impact of the seizure and guiding further medical care. However, during the seizure, immediate actions should focus on ensuring safety and managing the seizure itself.

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Correct Answer is B

Explanation

A. While oxygen saturation is important, it's not the priority in this situation. The client's symptoms strongly suggest hypoglycemia.
B. The client's symptoms of diaphoresis, rapid heartbeat, and shakiness are classic signs of hypoglycemia. Therefore, the first action should be to confirm this diagnosis by checking the blood glucose level.
C. Administering glucose before confirming hypoglycemia can be dangerous. If the client is hyperglycemic, giving them sugar will worsen their condition.
D. Providing food without confirming hypoglycemia is not appropriate.

A. Pneumonia B. Lung cancer C. Flu D. Chronic obstructive pulmonary disease (COPD) E. Chronic bronchitis

Correct Answer is ["B","E"]

Explanation

A. Pneumonia is an acute infection that causes inflammation in the lungs. While it can lead to significant respiratory symptoms and changes, it is not typically associated with clubbed nails. Clubbing usually develops over a longer period and is more common in chronic conditions.
B. Clubbing of the nails is often associated with lung cancer, particularly with bronchogenic carcinoma. The exact mechanism is not entirely clear, but it may relate to the presence of a malignancy causing systemic changes or the release of growth factors that affect nail tissue.
C. The flu is a viral respiratory infection that is usually acute and self-limiting. Clubbed nails are not a common manifestation of influenza. Clubbing is more associated with chronic respiratory and systemic conditions rather than acute viral infections.
D. COPD, which includes emphysema and chronic bronchitis, is not commonly associated with clubbing.

E. Chronic bronchitis, a type of COPD characterized by persistent cough and sputum production, may lead to clubbed nails in some cases. The chronic hypoxemia and long-term inflammation can contribute to this nail change, although it is less commonly seen than with other conditions.

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The nurse observes a client who begins to exhibit continuous jerking movements, is unable to speak, and is incontinent of urine during the event. Which action is most important for the nurse to take?

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Naxlex Comprehensive Predictor Exams

A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose Isophane suspension insulin at 0800. At 1600, the client reports having diaphoresis, rapid heartbeat, and feeling shaky. Which should the nurse do first?

Correct Answer is B

Explanation

Exhibits The nurse reviews client data. Select the 3 possible conditions that could have the clinical manifestation of clubbed nails for this client.

Correct Answer is ["B","E"]

Explanation

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