The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)?
Provide frequent mouth care.
Maintain the client in a semi-Fowler's position.
Ensure oral suction is available.
Keep the room at a comfortable temperature.
The Correct Answer is C
A. While frequent mouth care is important, it is not the most immediate concern during an active seizure. The priority is to maintain airway patency and prevent aspiration.
B. Maintaining a semi-Fowler's position may be beneficial, but the client’s level of consciousness and the presence of seizures require more immediate interventions focused on airway management.
C. Ensuring oral suction is available is essential for the client who is unconscious and experiencing seizures, as it allows for rapid intervention to clear secretions and prevent aspiration, which is critical for airway protection.
D. Keeping the room at a comfortable temperature is important for the overall comfort of the client, but it does not directly address the acute management of seizures and airway concerns.
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Correct Answer is C
Explanation
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B. Muscle cramping and dry, flushed skin are not typical indicators of levothyroxine overdose and may reflect other underlying issues.
C. Palpitations and shortness of breath are symptoms indicative of hyperthyroidism, suggesting that the levothyroxine dosage may be too high, leading to an increased metabolic rate and cardiovascular stress.
D. Lethargy and lack of appetite are more consistent with under-treatment or hypothyroidism rather than an overdose of levothyroxine, which typically stimulates metabolic activity.
Correct Answer is A
Explanation
A. Wearing braces or splints on both wrists at night helps to keep the wrists in a neutral position, preventing flexion that can worsen symptoms of carpal tunnel syndrome, particularly during sleep when the hands are more likely to be positioned in ways that exacerbate compression of the median nerve.
B. While notifying the healthcare provider is important if symptoms are severe, it is not the immediate teaching intervention the nurse should provide for symptom management.
C. Elevating the hands may help with swelling but is not the primary intervention for managing symptoms of carpal tunnel syndrome, especially pain and tingling.
D. Cold compresses may provide temporary relief but do not address the underlying issue of median nerve compression, which is better managed by using wrist braces.