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.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Appointing the client as a leader may not be appropriate, as individuals with antisocial personality disorder may misuse their position of authority.
Choice B rationale:
Clients with antisocial personality disorder often struggle with interpersonal relationships, may be manipulative, and may engage in behaviors that violate the rights of others. Monitoring the client's interactions with other clients helps ensure a safe and therapeutic environment while preventing harm to others.
Choice C rationale:
Offering warnings before consequences might not be effective with clients who have antisocial personality disorder, as they may disregard rules and consequences.
Choice D rationale:
Assigning a room near the activity area does not necessarily address the need to monitor the client's interactions with others.
Correct Answer is C
Explanation
Choice A rationale:
Thawing frozen foods at room temperature can promote bacterial growth, increasing the risk of foodborne illness.
Choice B rationale:
There is no need for the client to reduce their intake of calcium-containing foods specifically to prevent foodborne illness. Calcium-containing foods are not associated with an increased risk of bacterial contamination.
Choice C rationale:
Cooking raw fish and steak to the well-done stage is recommended to kill harmful bacteria and reduce the risk of foodborne illness, which is particularly important for individuals with neutropenia who are more susceptible to infections.
Choice D rationale:
Cutting damaged areas from fruits and vegetables is a good practice to reduce the risk of contamination, but it does not address the risk of bacterial contamination from undercooked meat and fish.
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