A nurse is assisting with the care of a client who has a seizure disorder. Which of the following supplies should the nurse have at the client's bedside at all times?
Suction equipment
Backboard
Padded tongue blades
Wrist restraints
The Correct Answer is A
Choice A: This is correct because suction equipment is essential for clearing the airway of secretions or vomitus during or after a seizure. The nurse should have suction equipment ready and accessible at the client's bedside at all times.
Choice B: This is incorrect because backboard is not needed for a client who has a seizure disorder. Backboard is used for immobilizing the spine in case of a suspected spinal injury.
Choice C: This is incorrect because padded tongue blades are not recommended for a client who has a seizure disorder. Padded tongue blades can cause injury to the teeth, gums, or tongue if inserted during a seizure. The nurse should never force anything into the mouth of a client who is having a seizure.
Choice D: This is incorrect because wrist restraints are not indicated for a client who has a seizure disorder. Wrist restraints can cause injury or skin breakdown if applied during a seizure. The nurse should never restrain or restrict the movements of a client who is having a seizure.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: The thigh-high stockings should reach just below the gluteal folds, not above them. If the stockings are too high, they can cause constriction and impair circulation.
Choice B reason: Reapplying the stockings before getting out of bed is an appropriate action. The client should remove the stockings at night and inspect the skin for any signs of irritation or breakdown. The client should also elevate the legs for 15 minutes before putting on the stockings to reduce edema and improve venous return.
Choice C reason: Flexing the toes when applying the stockings is not an appropriate action. The client should point the toes and foot downward when applying the stockings to prevent wrinkles or folds that can cause pressure ulcers.
Choice D reason: Rolling down knee-high stockings slightly to provide comfort is not an appropriate action. The client should avoid rolling or folding the stockings as this can create a tourniquet effect and impair blood flow.
Correct Answer is A
Explanation
Choice A reason: Applying a motion sensor mat to the client's bed is an appropriate action to prevent wandering and alert the staff if the client tries to get out of bed.
Choice B reason: Moving the overbed table away from the bed is not an effective action to prevent wandering, as it does not restrict the client's mobility or provide any supervision.
Choice C reason: Raising all four side rails while the client is in bed is an inappropriate action that can increase the risk of injury or entrapment if the client attempts to climb over them.
Choice D reason: Leaving the television on in the client's room is not an effective action to prevent wandering, as it does not provide any stimulation or distraction for the client.
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