A nurse is contributing to the plan of care for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan? (Select all that apply.)
Provide a suction setup at the bedside.
Elevate the side rails when in bed.
Place a bite stick at the bedside.
Keep an oxygen setup at the bedside.
Furnish restraints at the bedside.
Correct Answer : A,B,D
A. Provide a suction setup at the bedside:
This is a relevant intervention as it ensures that suction equipment is readily available in case the client experiences excessive secretions or vomiting during or after a seizure. It helps maintain a clear airway and prevent aspiration.
B. Elevate the side rails when in bed:
Elevating the side rails can help ensure the client's safety during a seizure by preventing falls from the bed. It is a preventive measure to minimize the risk of injury.
C. Place a bite stick at the bedside:
Placing a bite stick at the bedside is not a recommended intervention. Bite sticks can potentially injure the patient's teeth or mouth during a seizure and are generally not recommended in current practice.
D. Keep an oxygen setup at the bedside:
This is an appropriate intervention as it ensures that oxygen is readily available in case the client experiences respiratory distress or hypoxia during or after a seizure. Oxygen therapy may be needed to support respiratory function.
E. Furnish restraints at the bedside:
Furnishing restraints at the bedside is not a recommended intervention for managing seizures. Restraints should only be used in exceptional circumstances when the client's safety or the safety of others is at risk and should be applied according to institutional policies and legal regulations.
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Related Questions
Correct Answer is C
Explanation
A. Increased blinking
Increased blinking is not a typical manifestation of bradykinesia. In fact, individuals with Parkinson's disease may experience reduced blinking (hypokinesia of blinking) rather than increased blinking.
B. States of euphoria
Euphoria is not typically associated with bradykinesia. Instead, individuals with Parkinson's disease may experience a range of mood changes, including depression, anxiety, or apathy, but euphoria is not a common finding.
C. Slurred speech
This is the correct answer. Slurred speech, or dysarthria, can occur in individuals with Parkinson's disease as a result of bradykinesia affecting the muscles involved in speech production. Bradykinesia can cause a reduction in the speed and coordination of movements necessary for clear speech, resulting in slurred or mumbled speech patterns.
D. Decreased respiratory rate
Decreased respiratory rate is not typically associated with bradykinesia. Bradykinesia primarily affects voluntary movements rather than involuntary processes such as respiration. While respiratory muscle weakness can occur in advanced stages of Parkinson's disease, it is not directly related to bradykinesia.
Correct Answer is B
Explanation
A. Insert a padded tongue blade into the client's mouth.
This intervention is not recommended. Placing any object, including a padded tongue blade, into the mouth of someone experiencing a seizure poses a risk of injury, such as biting the tongue or breaking teeth. It can also obstruct the airway and increase the risk of aspiration. Therefore, inserting anything into the client's mouth during a seizure is contraindicated.
B. Place a pillow under the client's head.
Placing a pillow under the client's head can help prevent head injury by providing cushioning and support. It can also help maintain the client's airway and reduce the risk of aspiration. Therefore, this intervention is appropriate and helps ensure the client's safety during the seizure.
C. Gently restrain the client's extremities.
Restraining the client's extremities is not recommended during a seizure. It can increase the risk of injury, such as fractures or dislocations, and may exacerbate muscle contractions. It's important to allow the client's movements to occur naturally while taking measures to ensure their safety, such as removing nearby objects and providing a safe environment.
D. Keep the client in a supine position.
It is essential to ensure that the client's head is turned to the side (recovery position) to prevent aspiration and allow for drainage of oral secretions. Additionally, the nurse should remove any nearby objects that could pose a risk of injury during the seizure.
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