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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Rosebud-like Stoma Orifice
A rosebud-like stoma orifice is typically a normal appearance for a new stoma. The stoma should be moist, pink to red in color, and protrude slightly from the abdomen, resembling a rosebud. This appearance indicates good blood flow and proper healing. Therefore, this finding does not usually require immediate reporting to the provider.
Choice B: Stoma Oozing Red Drainage
While some minor bleeding or oozing can be normal immediately after surgery, persistent or significant red drainage from the stoma could indicate a complication such as infection or trauma to the stoma site. This finding should be monitored closely, but it is not as immediately concerning as a purplish-colored stoma, which indicates a more severe issue.
Choice C: Shiny, Moist Stoma
A shiny, moist stoma is a sign of a healthy stoma. The stoma should always appear moist and slightly shiny due to the mucus produced by the intestinal lining. This finding is normal and does not require reporting to the provider.
Choice D: Purplish-Colored Stoma
A purplish-colored stoma is an immediate concern and should be reported to the provider. This discoloration can indicate compromised blood flow to the stoma, which can lead to tissue necrosis if not addressed promptly. Ensuring adequate blood supply is crucial for the stoma’s viability and the patient’s overall health. Immediate medical intervention is necessary to prevent further complications.
Correct Answer is A
Explanation
Choice A Reason:
Hemoptysis, or coughing up blood, is a common feature of both mitral valve stenosis and mitral valve regurgitation. In mitral valve stenosis, the narrowing of the valve leads to increased pressure in the pulmonary veins, which can cause pulmonary congestion and hemoptysis. Similarly, in mitral valve regurgitation, the backflow of blood into the left atrium increases pulmonary pressure, potentially leading to pulmonary edema and hemoptysis. Therefore, hemoptysis is a shared symptom of both conditions.
Choice B Reason:
A high-pitched holosystolic murmur is more commonly associated with mitral valve regurgitation rather than mitral valve stenosis. In mitral valve regurgitation, the murmur is caused by the backflow of blood from the left ventricle into the left atrium during systole3. Mitral valve stenosis, on the other hand, typically presents with a diastolic murmur due to the turbulent flow of blood through the narrowed valve during diastole. Therefore, a high-pitched holosystolic murmur is not a common feature of both disorders.
Choice C Reason:
Hepatomegaly, or an enlarged liver, can occur in advanced cases of both mitral valve stenosis and mitral valve regurgitation due to right-sided heart failure. However, it is not a primary or common feature of these conditions. Hepatomegaly is more often associated with conditions that directly affect the right side of the heart or cause systemic congestion. Therefore, hepatomegaly is not a common feature of both mitral valve stenosis and mitral valve regurgitation.
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