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.

Answer and Explanation

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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Correct Answer is C

Explanation

A.While monitoring for elevated blood pressure is important in identifying autonomic dysreflexia once it occurs, it does not prevent the condition. The nurse should focus on eliminating potential triggers, such as bladder distention or constipation, to prevent the occurrence.

B.Headaches are a symptom of autonomic dysreflexia, often related to severe hypertension. While treating the headache may alleviate discomfort, it does not address the underlying cause, nor does it prevent the onset of autonomic dysreflexia.

C.Bladder distention is a common trigger for autonomic dysreflexia in individuals with spinal cord injuries. The nurse should ensure that the client's bladder is regularly emptied to prevent overdistention, which can stimulate the autonomic reflex and trigger AD.

D.Elevating the head is an intervention used during an episode of autonomic dysreflexia to help lower blood pressure and reduce symptoms. However, this action does not prevent the condition from occurring.

Correct Answer is ["0.6"]

Explanation

To calculate the dose of diazepam in mL, the nurse should use the formula:

Dose (mL) = Desired dose (mg) / Available dose (mg/mL)

Plugging in the values from the question, we get:

Dose (mL) = 3 mg / 5 mg/mL

Simplifying, we get:

Dose (mL) = 0.6 mL

Therefore, the nurse should administer 0.6 mL of diazepam IM.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?

Correct Answer is C

Explanation

A nurse is preparing to administer diazepam 3 mg IM. The amount available is diazepam for injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.6"]

Explanation

The nurse documents an abnormal finding from the Babinski reflex as a (the):

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