A nurse is caring for a client with a history of epilepsy who suddenly begins to experience a tonic-clonic seizure and loses consciousness. What would be the nurse's best action?
A. Restrain the client's extremities.
B. Turn the client's head to the side.
C. Take the client's blood pressure.
D. Place an airway into the client's mouth.
B
The nurse should turn the client's head to the side to prevent aspiration and allow drainage of secretions. The client should not be restrained nor an airway placed in the mouth during the sei-zure, because these actions increase seizure activity and can harm the client. Measurement of vital signs occurs in the postictal phase of the seizure.
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1. Risk for imbalanced body temperature. 2. Social isolation. 3. Decreased cardiac output. 4. Risk for activity intolerance.
A client is admitted owing to difficulty breathing. The nurse assesses the client's color, lung sounds, and pulse oximetry reading. The pulse oximetry is 90%. What is the nurse's next action?
a. Give an intermittent positive-pressure breathing treatment. b. Administer a rescue inhaler. c. Call for a chest x-ray. d. Assess an arterial blood gas.
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Indicate whether the statement is true or false.
A newly married client is attempting to fulfill the role of wife, professional, and lover. She tells the nurse that she does not feel that she is fulfilling any of the roles well. The nurse will document this as:
A) role strain. B) role ambiguity. C) role conflict. D) role transition.