A nurse is creating a plan of care for a client who has a history of tonicclonic seizure disorder. Which of the following interventions should the nurse Include? (Select all that apply.)

Furnish restraints at the bedside.

Elevate the side rails near the head when the client is in bed.

Place the bed in the lowest position

Provide a suction setup at the bedside.

Keep an oxygen setup at the bedside.

Answer and Explanation

Correct Answer : B,C,D,E

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Correct Answer is C

Explanation

Bruising over the cheek is a sign of facial trauma, not basilar skull fracture.

Missing teeth is a sign of dental injury, not basilar skull fracture.

Discoloration behind the left ear, also known as Battle's sign, is a sign of basilar skull fracture, as blood accumulates in the mastoid process due to a fracture in the temporal bone.

Bleeding from the nose is a sign of nasal trauma, not basilar skull fracture.

A. A 18 month old child learning how to walk who has a history of febrile seizure. B. A 35year old female who works at a steel mill and who has absence seizures. C. A 18year old highschool graduate who is enrolling in the Army. D. A75 year old female client with osteoporosis and who is on clopidogrel (Plavix) for atrial fibrillation.

Correct Answer is C

No explanation

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A nurse is creating a plan of care for a client who has a history of tonicclonic seizure disorder. Which of the following interventions should the nurse Include? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client arrived by EMS after a bar fight. He is disoriented with a Glasgow coma scale of 10. What additional finding indicates that he has suffered a basilar skull fracture?

Correct Answer is C

Explanation

Which of the following clients is most at risk for traumatic brain injury?

Correct Answer is C

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