A patient is experiencing a new onset of a seizure. What should the nurse include in this patient's plan of care? (Select all that apply.)
a. Suction if necessary.
b. Monitor vital signs when possible.
c. Place the patient in a supine position.
d. Restrain the patient to prevent injury.
e. Observe and document progression of symptoms.
f. Protect the patient from injury by removing nearby objects.
ANS: A, B, E, F
The patient should be protected from injury. Vital signs are monitored when able, if it will not injure the patient. Observing symptom progression can help diagnose the type of seizure, and suction may be necessary to prevent aspiration. C. The patient should be placed in a side-lying position if possible, not supine, to prevent aspiration. D. Restraining the patient increases the risk for injury.
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The nurse teaches the client to: (Select all that apply) 1. Drink liquid supplements to increase intake of nutrients. 2. Eat more warm foods and avoid cold foods. 3. Keep a food diary and record intake. 4. Eat small frequent meals high in calories. 5. Purchase fast foods and prepared foods.
Regular position changes:
a. Help prevent pressure ulcers and contrac-tures b. Protect you from injury and falls c. Cause discomfort and restlessness d. Are not done unless ordered by the doctor
After assessment of a patient in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which of the following as objective data?
A) Auscultation of the lungs B) Complaint of nausea C) Sensation of burning in her epigastric area D) Belief that demons are in her stomach
Change 27% to a ratio. ____________________
Fill in the blank(s) with correct word