The client takes a walk in the hallway and the nurse is present as the client has a seizure. Rank the nursing interventions in order beginning with the first action the nurse should implement
1. Remove nearby furniture.
2. Loosen restrictive clothing.
3. Maintain the client's airway.
4. Ease client to a safe location.
4, 3, 1, 2
4. Because the client is unsupported in the hallway, the nurse gently lowers the client to the floor to prevent injury from a fall.
3. The nurse cannot maintain the client's airway until the client is on a stable surface; because impaired airway is the client's greatest risk during a seizure, the airway is the nurse's second priority.
1. The nurse removes hazards to prevent client injury during the seizure.
2. Finally, the nurse loosens restrictive clothing to free the client of restraint; in addition, restrictive clothing can lead to skin breakdown as the client experiences the violent muscle contractions during a seizure.
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A homeless client is being admitted to the acute medical–surgical unit in a hospital. The nurse predicts which of the following as health risks for this client? Standard Text: Select all that apply
1. Improper nutrition 2. Lack of social support 3. Sleep needs usually met 4. Increased susceptibility to infection 5. Poor personal hygiene
5 : l00 = x : 325
x = _____ a. 0.65 b. 32.5 c. l.538 d. l6.25
The nurse is caring for a 10-year-old in traction. The boy has a nursing diagnosis of deficient diversional activity related to confinement in bed that is evidenced by verbalization of boredom and lack of participation in play, reading, and
schoolwork. Which of the following would be the best intervention? A) Offer the child reading materials. B) Enlist the aid of a child life specialist. C) Encourage the child to complete his homework. D) Ask for the parents' assistance.
Which subjective assessment data are most supportive of a client's diagnosis of anxiety?
a. "Client has diaphoretic and cool skin" b. "Client has an apical pulse rate of 120 beats per minute" c. "Client reports ‘needing to leave now'" d. "Client claims ‘something is terribly wrong'"