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 D

Explanation

A. Pupil response:

Pupil response refers to the reaction of the pupils to light stimulus. The pupils should normally constrict when exposed to bright light and dilate in dim light. Changes in pupil size or reactivity can indicate alterations in neurological function. For example, unequal or non-reactive pupils (anisocoria or fixed pupils) can be indicative of dysfunction in the cranial nerves or brainstem. However, while pupil response is an important aspect of neurological assessment, it may not always be the earliest indicator of cerebral status changes.

B. Deep tendon reflexes:

Deep tendon reflexes are involuntary muscle contractions in response to stretching of a muscle tendon. These reflexes are assessed by tapping the tendon with a reflex hammer, eliciting a rapid and brief muscle contraction. Changes in deep tendon reflexes can provide information about the integrity of the peripheral nervous system and spinal cord. However, alterations in deep tendon reflexes may occur secondary to changes in cerebral function and are typically assessed along with other neurological signs.

C. Muscle strength:

Muscle strength refers to the force generated by muscles during voluntary movement. It is typically assessed by asking the client to perform specific movements against resistance or by testing the strength of individual muscle groups using standardized scales (e.g., Medical Research Council scale). Changes in muscle strength can occur due to neurological or musculoskeletal conditions. While weakness or paralysis can result from lesions affecting the upper motor neurons (e.g., strokes or spinal cord injuries), alterations in muscle strength may not always be the earliest indicator of cerebral status changes.

D. Level of consciousness:

The level of consciousness refers to the degree of awareness and alertness exhibited by the client. It is assessed by evaluating the client's responsiveness, orientation, and ability to follow commands. Changes in the level of consciousness, such as confusion, lethargy, stupor, or coma, can indicate alterations in cerebral function and are often the earliest indicators of neurological dysfunction. Assessing the level of consciousness is a critical component of neurological examination and helps guide further assessment and management of clients with suspected brain tumors or other neurological conditions.

A. Lhermitte's sign B. Trigeminal neuralgia C. MS hug D. Paroxysmal spasms

Correct Answer is C

Explanation

A. Lhermitte's sign:

Lhermitte's sign is a neurological symptom characterized by a sensation of electric shock-like pain that radiates down the spine and into the limbs, typically triggered by flexing the neck forward. It is often described as shooting or stabbing pain and is commonly associated with lesions or damage to the cervical spinal cord. Lhermitte's sign is not associated with a tightening sensation around the torso but rather with shooting pain down the spine and limbs.

B. Trigeminal neuralgia:

Trigeminal neuralgia is a neurological condition characterized by severe, shooting pain along the trigeminal nerve, which supplies sensation to the face. The pain is typically triggered by activities such as chewing, speaking, or touching the face. Trigeminal neuralgia causes sudden, intense, electric shock-like pain in the face, particularly in the areas supplied by the trigeminal nerve (e.g., cheek, jaw, forehead). It is not associated with a tightening sensation around the torso.

C. MS hug:

The "MS hug" is a symptom experienced by some individuals with multiple sclerosis, characterized by a sensation of tightness, pressure, or squeezing around the chest, abdomen, or torso. It can feel like a band tightening around the body and may be described as a constricting or girdling sensation. The MS hug is caused by spasms or tightening of the muscles surrounding the rib cage or the intercostal muscles due to damage to the nerves that control muscle function in MS.

D. Paroxysmal spasms:

Paroxysmal spasms refer to sudden, involuntary muscle contractions or spasms that occur intermittently. These spasms can affect various parts of the body and are commonly associated with conditions like multiple sclerosis. However, they typically present as brief, sudden contractions rather than a persistent tightening sensation around the torso.

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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.)

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