The nurse identifies the diagnosis Risk for Trauma as appropriate for a client with a seizure disorder. Based on this diagnosis, which nursing interventions are appropriate when this client experiences a seizure?
Select all that apply.
A) Turn the client to a lateral position, if possible.
B) Stay with the client.
C) Insert a tongue blade into the client's mouth.
D) Call for help.
E) Restrain the client.
Answer: A, B, D
The nurse should stay with the client and call for assistance, if needed. If possible, the client should be turned onto the lateral position, not supine, to allow for any secretions to drain out of the mouth. Research has found that more injury can occur to the client if the caregiver tries to place something in the mouth during the seizure than if the caregiver does not. A client should never be restrained during a seizure.
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When assessing a client's integumentary status, the nurse notes a 1.0-cm, red, nonpalpable lesion on the client's arm. This should be recorded as a:
a. papule. c. patch. b. nodule. d. macule.
Ho is a middle-aged diabetic male of Asian descent. He moved to the United States about three years ago and continues to practice his traditional Asian cultural traditions
During his clinic visit the nurse reviewed his current medications, and was not too surprised when he told her that he also uses ginseng to help control blood sugar. It is important for the nurse to: 1. Advise Ho to only take the amount prescribed by his traditional healer. 2. Review possible interactions with his current medications. 3. Inform him that ginseng has been shown to be effective in clinical trials. 4. Ginseng can't hurt you because it is a natural plant-based remedy.
A nurse working with a post-surgery cardiac patient collaborates with him regarding the distance he will walk by the end of the week. The distance the patient completes is an example of a (n)
a. outcome. b. evidence based practice. c. nursing intervention. d. evaluation.
A nursing student has been assigned to provide care for a client who is from a different culture and who has recently been diagnosed with cancer
After talking with the client and her family, the student is surprised to learn that the client wants her eldest son to make most of the decisions around her care and treatment. How should the student best respond to this situation? A) Teach the client that she has the authority to make her own decisions while she is in the hospital. B) Speak to the son and encourage him to let his mother make decisions independently. C) Document this fact and ensure that a social worker gets involved in the client's care. D) Understand that the members of this culture may have dynamics that differ from his or her own culture.