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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Asking why the client enjoys gambling doesn't address the underlying issues of gambling disorder.
Choice B rationale:
Instructing the client to apologize to their family is judgmental and not therapeutic.
Choice C rationale:
Assuming the family's emotions and feelings is not appropriate and may not be accurate.
Choice D rationale:
Asking about the client's first experience with gambling can help uncover triggers and patterns related to the disorder, which can be useful for treatment.
Correct Answer is D
Explanation
Choice A rationale:
Hot flashes are not typically associated with postpartum depression; they are more related to hormonal changes.
Choice B rationale:
Intermittent abdominal pain is common after childbirth due to uterine contractions and involution.
Choice C rationale:
Blurred vision is not a typical symptom of postpartum depression.
Choice D rationale:
Feelings of intense guilt are indicative of postpartum depression and require further investigation.
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