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 B
Explanation
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C. While sitting up after meals can aid digestion, it is not a primary dietary instruction for managing diverticulosis.
D. A bland diet may not be necessary; the focus should be on increasing fiber intake rather than avoiding specific flavors or spices unless they cause discomfort.
Correct Answer is B
Explanation
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B. Right-sided heart failure is characterized by fluid overload, leading to symptoms like pitting edema in the extremities and jugular venous distention, which align with the findings observed in this client.
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D. Cardiac tamponade may present with jugular venous distention, but it usually also involves hypotension and muffled heart sounds, which are not described in this scenario.