The nurse in the intensive care unit enters her patient's room and observes the patient is experiencing a seizure. What are the most appropriate interventions by the nurse? Select all that apply
a. Insert a padded tongue depressor in the patient's mouth.
b. Turn the patient to his side.
c. Restrain the patient to control his jerking movements.
d. Loosen any restrictive clothing.
e. Pad the siderails of the patient's bed.
B, D, E
When a seizure is occurring, the nurse would turn the patient to his side to prevent aspiration and loosen any restrictive clothing; also pad the head, foot, and siderails of the bed and place oral suction at the bedside. Do not try to open the mouth and insert a tongue depressor. This action could result in injury to the patient or injury to the nurse (biting). Also do not attempt to restrain the patient, as this may result in muscle and joint injury.
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A 16-year-old patient is diagnosed with primary hypertension. What risk factors does the nurse mention when providing education on this diagnosis to the patient and his family? (Select all that apply.)
a. Heredity b. Stress c. Congenital defect d. Obesity e. Poor diet
Children of a widow confer with the nurse because their mother repeatedly tells details of finding her husband not breathing, performing CPR, the trip to the hospital, and seeing him pronounced dead
Family members are concerned that this is traumatic to others hearing the story and ask, "What can we do?" The nurse should counsel the family that: a. they should express their feelings to their mother and ask her not to retell the story. b. the retelling should be limited to once daily to avoid unnecessary stimulation. c. repeating the story and her feelings is a helpful and necessary part of grieving. d. retelling of memories is expected as part of the aging process.
A 25-year-old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled for discharge. As you prepare her for discharge, she begins to cry. Your initial action should be to
a. Assess her for pain. b. Point out how lucky she is to have a healthy baby. c. Explain that she is experiencing postpartum blues. d. Allow her time to express her feelings.
Incomplete protein
a. has no nutritional value in the diet. b. is mostly found in foods of animal origin. c. has been denatured by contact with heat, acid, or alkali. d. contains inadequate amounts of one or more essential amino acids.