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 D
Explanation
Choice A rationale:
Replacing the ritual with a different ritualistic behavior is possible, but it does not necessarily predict the initial response when the restriction is first imposed.
Choice B rationale:
Reporting auditory hallucinations is not a typical response to restricting ritualistic behavior in someone with OCD.
Choice C rationale:
Expressing relief from not having to perform the ritual is unlikely, as ritualistic behaviors in OCD are often driven by distress and anxiety.
Choice D rationale:
If ritualistic behavior is restricted in an individual with obsessive- compulsive disorder (OCD), they may experience panic-level anxiety due to their inability to engage in their usual coping mechanism. OCD rituals are often performed to reduce anxiety, and restricting them can lead to increased distress.
Correct Answer is A
Explanation
Choice A rationale:
Low dietary intake of fiber is a significant risk factor for diverticular disease. A diet low in fiber can lead to constipation and increased pressure in the colon, contributing to the formation of diverticula.
Choice B rationale:
Prolonged use of steroids is not a primary risk factor for diverticular disease.
Choice C rationale:
Insufficient intake of protein is not a significant risk factor for diverticular disease.
Choice D rationale:
Family history of gallbladder disease is not directly associated with an increased risk of diverticular disease.
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