A nurse is implementing seizure precautions for a client who has had a tonic-clonic seizure.
Which of the following interventions should the nurse include in the plan of care?

Provide a tracheostomy tray at the bedside.

Place the client in a supine position.

Place a plastic tongue depressor at the client's bedside.

Insert an IV saline lock.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D: Insert an IV saline lock.

Choice D rationale: Inserting an IV saline lock is an appropriate nursing intervention for a client with a tonic-clonic seizure. This allows for quick access to administer intravenous medications, such as anticonvulsants, in case the client experiences another seizure.

Choice A rationale: Providing a tracheostomy tray at the bedside is not necessary for seizure precautions. While maintaining a patent airway is essential during a seizure, it can typically be managed with proper positioning and suctioning if necessary.

Choice B rationale: Placing the client in a supine position is not recommended for seizure precautions. Instead, the client should be placed in a semi-prone or lateral position to promote drainage of secretions and prevent aspiration.

Choice C rationale: Placing a plastic tongue depressor at the client's bedside is not an appropriate intervention. Attempting to insert an object into the client's mouth during a seizure can cause injury and is not recommended.

In summary, the nurse should include inserting an IV saline lock as part of the plan of care for a client who has experienced a tonic-clonic seizure. This will allow for rapid administration of medications, if necessary, while prioritizing client safety and adhering to seizure precautions.

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Correct Answer is A

Explanation

Choice A rationale:

The described cardiac rhythm with a wavy baseline, no distinguishable P waves, and an increased heart rate is consistent with atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to an irregular and often rapid heart rate. This rhythm is characterized by the absence of distinct P waves on the ECG.

Choice B rationale:

Ventricular asystole is a flatline on the ECG, indicating the absence of electrical activity in the heart. It is a life-threatening arrhythmia and requires immediate intervention with cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) protocols.

Choice C rationale:

Second-degree heart block is characterized by intermittent failure of atrial electrical impulses to conduct to the ventricles. This results in occasional dropped beats and a varying heart rate. It is not consistent with the described ECG findings in the question.

Choice D rationale:

Sinus tachycardia is a regular, fast heart rate originating from the sinoatrial (SA) node. In sinus tachycardia, P waves are present, indicating that the electrical impulses originate in the SA node. The described ECG findings do not match the characteristics of sinus tachycardia.

A. "Tell me what concerns you have about using a bedpan." B. "Make sure to use nearby furniture to support yourself when walking to the bathroom." C. "You have to use the bedpan for your own safety." D. "I will have the physical therapist ambulate you to the bathroom." .

Correct Answer is A

Explanation

Choice A rationale:

The nurse should prioritize the client's concerns and engage in therapeutic communication. By asking the client about their concerns, the nurse demonstrates empathy and encourages the client to express their feelings, which can help address any fears or anxieties related to using a bedpan. This approach promotes trust and allows the nurse to provide appropriate support and education to the client.

Choice B rationale:

This option does not address the client's concerns about using a bedpan. Instructing the client to use nearby furniture does not address the client's emotional needs or provide appropriate assistance for the current situation.

Choice C rationale:

This response is authoritarian and does not respect the client's autonomy or emotional state. It may cause the client to feel powerless and anxious, which can negatively impact the nurse-client relationship.

Choice D rationale:

Involving the physical therapist in this situation is unnecessary and does not address the client's immediate concern. It also does not promote open communication between the nurse and the client about the client's feelings regarding using a bedpan.

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A nurse is implementing seizure precautions for a client who has had a tonic-clonic seizure. Which of the following interventions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring.The cardiac rhythm strip shows a wavy baseline, no distinguishable P waves, and an increased heart rate.The nurse should identify the cardiac rhythm as which of the following?

Correct Answer is A

Explanation

A nurse is caring for a client who is near the end of life and is on complete bed rest.The client states that he needs to have a bowel movement and the nurse offers a bedpan.The client states, "I've always used the bathroom." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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A nurse is implementing seizure precautions for a client who has had a tonic-clonic seizure.
Which of the following interventions should the nurse include in the plan of care?