What is the first nursing action for a client who develops a seizure?

Correct Answer: A

Rationale: The correct answer is A: Place the client on their side. This is the first nursing action for a client who develops a seizure to prevent aspiration and maintain an open airway. Placing the client on their side helps to keep their airway clear and prevents them from choking on saliva or vomit. Choice B, loosening clothing, is important but not the first priority. Choice C, placing the client in a Trendelenburg position, is not recommended as it may increase intracranial pressure. Choice D, placing the client in a sitting position, can increase the risk of injury during a seizure.

Correct Answer: B

Rationale: The correct answer is B: Provide cooling measures. When caring for a client with hyperthermia, the nurse's priority is to lower the body temperature to prevent further complications. Providing cooling measures such as removing excess clothing, using fans, applying cool compresses, and encouraging hydration helps to reduce the body temperature effectively. Administering antipyretics (A and D) may be considered in some cases, but cooling measures are more immediate and effective. Administering corticosteroids (C) is not indicated in the treatment of hyperthermia. Cooling measures directly target the elevated body temperature, making it the top priority in managing hyperthermia.

Correct Answer: D

Rationale: The correct answer is D: Objective. During a physical assessment, the nurse gathers data through observation and measurement, such as vital signs and physical appearance, which are objective and measurable. This type of data is based on facts rather than opinions or interpretations, making it reliable for assessing the client's health status. Patient-centered data (A) refers to information focused on the client's perspective, subjective data (B) is based on the client's symptoms or feelings, and unconfirmed data (C) lacks validation or evidence, making them unreliable for making clinical decisions.

Correct Answer: C

Rationale: Step-by-step rationale: 1. Total parenteral nutrition (TPN) can cause adrenal insufficiency. 2. Corticosteroids help prevent adrenal insufficiency in TPN patients. 3. Monitoring corticosteroid administration ensures adrenal function. 4. Monitoring blood glucose or serum glucose levels is important but not specific to TPN. 5. Dehydration can be monitored but is not directly related to TPN.

Correct Answer: D

Rationale: The correct answer is D: A high-fat meal. After gastric resection, high-fat meals are likely to cause rapid gastric emptying due to the delayed gastric emptying effect of fats. Fats take longer to digest compared to other nutrients, leading to slower emptying of the stomach contents. This can result in rapid emptying of the stomach post-resection. A: A high-protein meal does not necessarily cause rapid gastric emptying as proteins are digested at a moderate pace. B: A large meal regardless of nutrient content may lead to slower gastric emptying due to the increased volume. C: A high-carbohydrate meal can promote quicker gastric emptying, but it is not as likely to cause rapid emptying as high-fat meals post-gastric resection.

Correct Answer: A

Rationale: The correct answer is A: Provide hydration. During chemotherapy, hydration is crucial to prevent dehydration and maintain kidney function. Chemotherapy drugs can be nephrotoxic and cause electrolyte imbalances. Hydration supports drug clearance and prevents kidney damage. Administering oxygen (B) is not typically a priority unless the client is experiencing respiratory distress. Administering pain medications (C) may be important but is not the priority over hydration. Monitoring for signs of infection (D) is important but providing hydration to prevent dehydration and maintain kidney function takes precedence.

Correct Answer: B

Rationale: The correct answer is B: Provide oxygen therapy. For a client with shortness of breath and a history of heart failure, oxygen therapy is the most effective intervention as it helps improve oxygenation and relieve respiratory distress. Administering diuretics may help manage fluid retention but does not directly address the breathing difficulty. Encouraging deep breathing may be beneficial for some respiratory conditions but may not be sufficient for a client with heart failure and shortness of breath. Applying oxygen therapy is similar to providing oxygen therapy and can help improve oxygen levels, but providing oxygen therapy is more specific and effective in this case.

Correct Answer: A

Rationale: The correct answer is A: Place the client on their side. This is the first nursing action for a client who develops a seizure to prevent aspiration and maintain an open airway. Placing the client on their side helps to keep their airway clear and prevents them from choking on saliva or vomit. Choice B, loosening clothing, is important but not the first priority. Choice C, placing the client in a Trendelenburg position, is not recommended as it may increase intracranial pressure. Choice D, placing the client in a sitting position, can increase the risk of injury during a seizure.

Correct Answer: C

Rationale: The correct answer is C because promoting health in the client is essential in achieving high-level wellness. Nurses play a crucial role in educating, empowering, and supporting clients in making healthy lifestyle choices. By promoting health, nurses help clients prevent illness, maintain optimal well-being, and improve their overall quality of life. Encouraging appointment attendance (choice A) is important but not solely focused on wellness promotion. Providing information on alternative treatments (choice B) is valuable but may not directly contribute to high-level wellness. Providing good client care (choice D) is a fundamental nursing responsibility, but it does not specifically address the promotion of health and wellness.