A client has a prescription for seizure precaution. Which intervention should the nurse include in the plan of care?
Keep the bed in the highest position
Keep seizure medication at the bedside at all times
Keep very bright lights in the client's room during the night
Keep the bed locked in the lowest position .
Keep the bed locked in the lowest position .
The Correct Answer is B
Choice A is incorrect. While keeping the bed in a high position can minimize fall risk, it is not a specific precaution for preventing seizures. In fact, some types of seizures can be triggered by sudden changes in position.
Choice C is incorrect. Bright lights can worsen seizure activity and should be avoided, especially during the night when the client is more likely to be photosensitive.
Choice D is incorrect. Locking the bed in the lowest position can increase fall risk and is not a specific precaution for preventing seizures.
Rationale for Choice B:
Having seizure medication readily available at the bedside allows for immediate administration in case of a seizure, which can minimize its duration and severity. This is a crucial intervention for seizure precaution.
Keeping the medication within easy reach also ensures prompt administration by healthcare personnel or caregivers, further improving the client's safety and outcome.
Additionally, easy access to the medication empowers the client or caregiver to participate actively in their own care and respond quickly to a potential seizure.
Therefore, based on the importance of immediate access to seizure medication in managing and preventing seizures, Choice B is the most appropriate intervention to include in the client's plan of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Exercise.
Choice A: Exercise Exercise is generally beneficial for overall health and is not typically a factor that exacerbates systemic lupus erythematosus (SLE). In fact, regular physical activity can be an important part of the overall treatment plan for individuals with SLE. It can boost energy levels, improve joint flexibility, and help alleviate stress. Therefore, if a patient with SLE identifies exercise as a factor that can exacerbate their condition, it indicates a need for further teaching.
Choice B: Diet Certain diets can potentially trigger or worsen SLE symptoms. For instance, a chemical found in alfalfa may trigger lupus symptoms, so patients may want to avoid eating alfalfa sprouts or taking supplements with alfalfa. Therefore, diet is a correct factor that can exacerbate SLE.
Choice C: Sunlight Exposure to sunlight can trigger or worsen SLE symptoms. For those with lupus, being in the sun can lead to symptoms like skin rashes, itching, burning, joint pain, weakness, and fatigue. In certain cases, it can also result in damage to internal organs. Therefore, sunlight is a correct factor that can exacerbate SLE.
Choice D: Infection Infections can trigger or worsen SLE symptoms. Rates of infections are higher among persons with SLE compared with the general population. Therefore, infection is a correct factor that can exacerbate SLE.
Correct Answer is C
Explanation
Choice A rationale:
Restricting weight-bearing on the affected foot may provide some temporary relief from pain during an acute gout attack. However, it is not a long-term management strategy and can lead to muscle weakness and joint stiffness. It's important to gradually resume weight-bearing activities as tolerated to maintain joint function.
Choice B rationale:
Adequate fluid intake is essential for overall health and can help to flush out uric acid from the body. However, 8 liters per day is an excessive amount of fluid and could lead to electrolyte imbalances and other health problems. A more appropriate recommendation for a client with gout would be to aim for a fluid intake of 2-3 liters per day, unless otherwise advised by a healthcare provider.
Choice C rationale:
Restricting consumption of foods high in purines is a key management strategy for gout. Purines are substances found in certain foods that break down into uric acid in the body. High levels of uric acid can lead to the formation of urate crystals, which deposit in joints and cause inflammation and pain. Examples of foods high in purines include organ meats, red meat, seafood, and some types of beans and lentils.
Choice D rationale:
Calcium supplements have not been shown to be effective in the management of gout. In fact, some studies have suggested that calcium supplements may even increase the risk of gout attacks.
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