A nurse is caring for a client who has a seizure disorder.

Exhibits

A nurse is caring for a client who has a seizure disorder. What following actions should the nurse take? (Select all that apply.)

Time the duration of the seizure.

Administer supplemental oxygen to the client.

Place a tongue depressor in the client’s mouth.

Turn the client to the side.

Restrain the client.

Answer and Explanation

Correct Answer : A,B,D

Choice A: Time the duration of the seizure

Reason: Timing the duration of a seizure is crucial for several reasons. Firstly, it helps in determining the type of seizure and its severity. Seizures lasting more than 5 minutes are considered medical emergencies and may require immediate intervention to prevent complications such as status epilepticus, which is a prolonged seizure that can cause brain damage or death. By recording the start and end times, healthcare providers can assess the effectiveness of treatments and make necessary adjustments. Additionally, this information is vital for documenting the patient’s medical history and for future reference in managing the condition.

Choice B: Administer supplemental oxygen to the client

Reason: Administering supplemental oxygen is essential during a seizure, especially when the client’s oxygen saturation levels drop below the normal range of 95-100%. In the provided scenario, the client’s oxygen saturation is 86%, which is significantly low and indicates hypoxemia. Hypoxemia can lead to further complications, including brain damage due to insufficient oxygen supply. Providing supplemental oxygen helps maintain adequate oxygen levels in the blood, ensuring that vital organs, including the brain, receive enough oxygen to function properly. This intervention is critical in preventing hypoxic injuries and promoting recovery post-seizure.

Choice C: Place a tongue depressor in the client’s mouth

Reason: Placing a tongue depressor in the client’s mouth during a seizure is not recommended and can be dangerous. This outdated practice was once believed to prevent the client from biting their tongue, but it poses significant risks. The client could bite down on the depressor, causing dental injuries or even breaking the depressor, leading to choking hazards. Modern seizure management guidelines advise against placing any objects in the mouth during a seizure. Instead, the focus should be on ensuring the client’s safety by clearing the area of any harmful objects and positioning them safely.

Choice D: Turn the client to the side

Reason: Turning the client to the side, also known as the recovery position, is a critical intervention during a seizure. This position helps maintain an open airway and reduces the risk of aspiration, which can occur if the client vomits or has excessive saliva. Aspiration can lead to serious respiratory complications, including pneumonia. By positioning the client on their side, gravity helps drain fluids from the mouth, preventing them from entering the airway9. This simple yet effective measure is a standard practice in seizure management to ensure the client’s safety and comfort.

Choice E: Restrain the client

Reason: Restraining a client during a seizure is not recommended and can be harmful. Seizures involve involuntary muscle contractions, and attempting to restrain the client can lead to injuries such as fractures, muscle tears, or dislocations. Additionally, restraint can increase the client’s agitation and stress, potentially worsening the seizure. The appropriate approach is to ensure the client’s safety by removing nearby objects that could cause injury and allowing the seizure to run its course. Gentle guidance and support should be provided without applying force.

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Correct Answer is C

Explanation

Choice A reason: Wearing heels up to 2 inches in height can contribute to lower back pain by altering posture and increasing the strain on the lower back muscles. It is generally recommended to wear low-heeled or flat shoes to reduce the risk of exacerbating back pain.

Choice B reason: Sleeping lying flat with legs extended straight is not the best position for someone with lower back pain. It is often recommended to sleep on the side with knees slightly bent or on the back with a pillow under the knees to maintain the natural curve of the spine and reduce strain.

Choice C reason: Keeping weight within 10 percent of ideal weight is important for managing lower back pain. Excess weight, especially around the abdomen, can put additional strain on the lower back muscles and spine, exacerbating pain. Maintaining a healthy weight through diet and exercise can help alleviate back pain.

Choice D reason: Increasing high potassium foods in the diet is beneficial for overall health but is not specifically related to managing lower back pain. Potassium helps with muscle function and can prevent cramps, but it does not directly address the causes of lower back pain.

A. Provide bedtime rituals. B. Encourage play exercises in the evening. C. Explain the source of the toddler’s fears. D. Turn off the room light.

Correct Answer is A

Explanation

Choice A reason:

The statement “Provide bedtime rituals” is correct. Establishing a consistent bedtime routine can help toddlers feel more secure and relaxed, which can promote better sleep. Bedtime rituals might include reading a story, singing a lullaby, or having a warm bath before bed. These activities signal to the child that it is time to wind down and prepare for sleep.

Choice B reason:

The statement “Encourage play exercises in the evening” is incorrect. While physical activity is important for overall health, engaging in stimulating play exercises right before bedtime can make it harder for toddlers to settle down and fall asleep. It is better to encourage quiet, calming activities in the evening.

Choice C reason:

The statement “Explain the source of the toddler’s fears” is not the most effective approach for promoting sleep. While addressing fears is important, the explanation alone may not be sufficient to help the toddler feel secure enough to sleep. Providing comfort and reassurance through bedtime rituals is more effective in creating a sense of safety.

Choice D reason:

The statement “Turn off the room light” is partially correct but not the best standalone solution. While a dark environment can promote sleep, some toddlers may feel more secure with a nightlight. The focus should be on creating a calming and comfortable sleep environment, which includes but is not limited to adjusting the lighting.

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A nurse is caring for a client who has a seizure disorder. Exhibits A nurse is caring for a client who has a seizure disorder. What following actions should the nurse take? (Select all that apply.)

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A nurse is caring for a client who has a seizure disorder.

Exhibits

A nurse is caring for a client who has a seizure disorder. What following actions should the nurse take? (Select all that apply.)