A nurse is developing a plan of care for a client who has epilepsy and was admitted after experiencing a tonic-clonic seizure. Which of the following interventions should the nurse include in the plan?
Ensure padded wrist restraints are in the client's room.
Initiate IV access for the client.
Administer lorazepam every 4 hr to sedate the client.
Place an incontinence brief on the client
The Correct Answer is B
Choice A rationale:
Padded wrist restraints are not appropriate unless there's a clear clinical indication to prevent self-harm or injury.
Choice B rationale:
After a seizure, it's important to establish IV access for the client to administer medications, fluids, or other interventions if needed. Monitoring for possible postictal state, airway patency, and vital signs are also important components of care.
Choice C rationale:
Administering lorazepam every 4 hours is not a standard protocol for post-seizure management and could lead to excessive sedation.
Choice D rationale:
Placing an incontinence brief is not necessary unless there's a specific indication, and it doesn't directly relate to post-seizure care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Inflammatory bowel disease, including Crohn's disease, can lead to decreased albumin levels due to malabsorption and inflammation.
Choice B rationale:
Increased erythrocyte sedimentation rate (ESR) is more likely in inflammatory conditions.
Choice C rationale:
Decreased hematocrit is more common due to potential blood loss.
Choice D rationale:
Decreased protein levels are expected due to inflammation and malabsorption.
Correct Answer is {"xRanges":[299.765625,329.765625],"yRanges":[366.609375,396.609375]}
Explanation
Choice A rationale: This is incorrect because at about one hour after child birth the fundus should be around the belly button (where it was at 20 weeks of gestation).
Choice B rationale: This is incorrect because at about one hour after child birth the fundus should be around the belly button (where it was at 20 weeks of gestation). It then decreases steadily at approximately 1 cm every 24 hours.
Choice C rationale: One-week post-partum, the fundal height should be about 7 cm below the umbilicus (belly button). This means that the uterus is still larger than normal, but it is contracting and healing. The fundal height may vary depending on factors such as the size and position of the baby, the amount of amniotic fluid, and the mother's body type.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.