Which information must be included when documenting a patient's seizure? (Select all that apply.)
a. Time of seizure onset
b. Total duration of the seizure
c. Patient's ability to swallow during seizure
d. Incontinence during seizure
e. Patient orientation after seizure
A, B, D, E
When a patient has a seizure, documentation should include time of seizure onset, time of seizure termination, total duration of seizure, and characteristics of the seizure (e.g., location of tonic or clonic movement, pupil changes, cyanosis, incontinence, and patient orientation level after the seizure). While it is a good idea to assess swallowing ability after a seizure, during the seizure is not the time to do this.
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A nurse cares for a client who recently completed genetic testing that revealed that she has a BRCA1 gene mutation. Which actions should the nurse take next? (Select all that apply.)
a. Discuss potential risks for other members of her family. b. Assist the client to make a plan for prevention and risk reduction. c. Disclose the information to the medical insurance company. d. Recommend the client complete weekly breast self-examinations. e. Assess the client's response to the test results. f. Encourage support by sharing the results with family members.
The nurse is assessing a client's sensory reception and perception. The client has a history of a motor vehicle accident several years ago that resulted in a spinal cord injury
This client is at risk for altered sensory reception of which type of stimuli? 1. Visual 2. Auditory 3. Gustatory 4. Visceral
A 22-year-old male arrives at the ED following a motor vehicle collision. He is not awake and is being bagged with a bag-valve-mask by paramedics
He has sustained obvious injuries to his head and face as well as an open right femur fracture that is bleeding profusely. What should the nurse's initial intervention be? A. Splint the right lower extremity to decrease blood loss. B. Apply direct pressure to the open area on the right leg. C. Assess for a patent airway. D. Start two large-bore intravenous lines.
A patient, being treated for acute gastrointestinal bleeding, is receiving 0.9% normal saline at 200 mL/hour through two large-bore IVs. What assessment finding would the nurse report immediately to the physician?
1. Crackles in both lung bases 2. Urinary output of 50 mL in 1 hour 3. Capillary refill of less than 2 seconds 4. Approximately 200 mL of coffee ground emesis