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A client has been admitted with new-onset status epilepticus. Which seizure precautions would the nurse implement? (Select all that apply.)

Suction equipment at the bedside.

Continuous sedation.

Side rails padded.

Bed in low position.

Intravenous (IV) access.

Answer and Explanation

Correct Answer : A

Choice A Reason:

Suction equipment at the bedside.

Having suction equipment at the bedside is crucial for a client with status epilepticus. During a seizure, there is a risk of aspiration due to excessive salivation or vomiting. Suction equipment allows the nurse to quickly clear the airway, preventing aspiration and ensuring the client can breathe properly. This precaution is essential to maintain the client’s airway and prevent complications such as aspiration pneumonia.

Choice B Reason:

Continuous sedation.

Continuous sedation is not typically a standard precaution for all clients with status epilepticus. While sedation may be necessary in some cases to control seizures, it is not a universal precaution. The primary goal is to stop the seizure activity and stabilize the client. Continuous sedation may be used in specific situations under close medical supervision, but it is not a general precaution that nurses implement for all clients with status epilepticus.

Choice C Reason:

Side rails padded.

Padding the side rails of the bed is an important precaution to prevent injury during a seizure. Clients experiencing seizures may have uncontrolled movements, which can lead to injury if they hit the hard surfaces of the bed. Padded side rails help to cushion these impacts, reducing the risk of bruises, cuts, or fractures. This precaution is essential for ensuring the client’s safety during seizure activity.

Choice D Reason:

Bed in low position.

Keeping the bed in a low position is another important safety measure. If a client with status epilepticus were to fall out of bed during a seizure, the lower height reduces the risk of serious injury. This precaution helps to minimize the impact of any potential falls, ensuring the client’s safety. It is a simple yet effective measure to prevent harm during seizure episodes.

Choice E Reason:

Intravenous (IV) access.

Establishing intravenous (IV) access is critical for a client with status epilepticus. IV access allows for the rapid administration of medications needed to control seizures and manage the client’s condition. In an emergency, quick access to the bloodstream is essential for delivering life-saving treatments. This precaution ensures that the medical team can promptly and effectively intervene to stop the seizure activity.

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Correct Answer is ["31"]

Explanation

Step 1: Calculate the total infusion time in minutes.

8 hours × 60 minutes/hour = 480 minutes

Result at each step = 480 minutes

Step 2: Calculate the total number of drops to be infused.

1,000 mL × 15 drops/mL = 15,000 drops

Result at each step = 15,000 drops

Step 3: Calculate the infusion rate in drops per minute.

15,000 drops ÷ 480 minutes = 31.25 drops/minute

Result at each step = 31.25 drops/minute

Step 4: Round to the nearest whole number if necessary.

31.25 drops/minute rounds to 31 drops/minute

Result at each step = 31 drops/minute

Therefore, the nurse should run the IV infusion at a rate of 31 drops per minute.

A. Client who displays plantar flexion when the bottom of the foot is stroked. B. Client who consistently demonstrates decortication when stimulated. C. Client whose Glasgow Coma Scale (GCS) has changed from 15 to 12. D. Client whose deep tendon reflexes have become hyperactive.

Correct Answer is C

Explanation

Choice A Reason:

The client who displays plantar flexion when the bottom of the foot is stroked is exhibiting a normal reflex response known as the plantar reflex. This response indicates that the corticospinal tract is functioning properly. In adults, the normal response is plantar flexion of the toes, which means the toes curl downward. This is not an immediate cause for concern and does not indicate a life-threatening condition.

Choice B Reason:

The client who consistently demonstrates decortication when stimulated is showing signs of severe brain injury. Decorticate posturing is characterized by the arms being flexed at the elbows and held tightly to the chest, with the legs extended and feet turned inward. This type of posturing indicates damage to the cerebral hemispheres, thalamus, or midbrain. While this is a serious condition, it is not necessarily the most immediate priority compared to a sudden change in the Glasgow Coma Scale.

Choice C Reason:

The client whose Glasgow Coma Scale (GCS) has changed from 15 to 12 is the nurse’s first priority. The GCS is a critical tool used to assess a patient’s level of consciousness, with scores ranging from 3 (deep coma) to 15 (fully awake and alert). A drop in GCS score indicates a significant decline in neurological function, which could be due to increased intracranial pressure, bleeding, or other acute changes in the brain. This requires immediate assessment and intervention to prevent further deterioration.

Choice D Reason:

The client whose deep tendon reflexes have become hyperactive is showing signs of hyperreflexia. Hyperactive reflexes can indicate an upper motor neuron lesion, which affects the descending corticospinal tract. While this is a concerning sign that warrants further investigation, it is not as immediately critical as a sudden change in the GCS score.

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A client has been admitted with new-onset status epilepticus. Which seizure precautions would the nurse implement? (Select all that apply.)

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