A nurse is planning care for a client who has a seizure disorder. Which of the following equipment should the nurse place in the client's room?
Tongue blade
NG tube
Oral airway
Wrist restraints
The Correct Answer is C
Choice A reason : A tongue blade should not be placed in the mouth during a seizure as it can cause injury or obstruct the airway.
Choice B reason: An NG tube, or nasogastric tube, is not typically required in the immediate management of seizures and should not be inserted during an active seizure due to the risk of injury.
Choice C reason: An oral airway may be used to maintain a patent airway during a postictal state if the client is unable to maintain their own airway.
Choice D reason: Wrist restraints are not routinely recommended for clients with seizure disorders as they can cause injury during a seizure. Safe environment and proper positioning are preferred to prevent injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason : Muscle twitching can be indicative of hypocalcemia, a common and serious complication following a complete thyroidectomy due to potential damage or removal of the parathyroid glands. Hypocalcemia requires immediate intervention to prevent more severe symptoms such as tetany or cardiac complications.
Choice B reason : While nausea is a common postoperative symptom, it is not typically as urgent as signs of hypocalcemia. However, persistent nausea should still be addressed as it can affect the client's comfort and nutritional intake.
Choice C reason : Serosanguineous drainage is expected to some extent after surgery, but if it is excessive or changes in character, it may indicate hemorrhage or infection, which would then become a priority.
Choice D reason : Incisional pain is also expected postoperatively. While pain management is important for recovery, it is not as immediately concerning as potential hypocalcemia unless the pain is severe or uncontrolled, suggesting complications.
Correct Answer is D
Explanation
Choice A reason: While it is generally advised to avoid taking blood pressure readings from an arm with a PICC line to prevent complications, if the right arm cannot be used, as may be the case with the other clients listed, the nurse may have to use the left arm with extreme caution, ensuring not to disrupt the PICC line.
Choice B reason: Bell's palsy affects facial nerves and does not typically impact the measurement of blood pressure. Therefore, there is no contraindication to using the left arm for a blood pressure reading in a client with left-sided Bell's palsy.
Choice C reason: A client with right-sided weakness due to Parkinson's disease can have their blood pressure taken on the left side if the right side is too weak to provide an accurate reading or if using the right side would cause discomfort to the client.
Choice D reason: For a client with a right upper extremity arteriovenous fistula, typically created for dialysis access, blood pressure measurements should not be taken on that arm to avoid damaging the fistula. Therefore, the left arm should be used for blood pressure readings in this case.
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