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 B
Explanation
Choice A reason: Papilledema, which is the swelling of the optic disc due to increased ICP, is not typically an early sign. It is usually a later manifestation because it takes time for the pressure to build up and affect the optic nerve.
Choice B reason: Restlessness can be an early sign of increased ICP. As ICP begins to rise, it can cause subtle changes in a person's level of consciousness, leading to agitation or restlessness. This is often one of the first signs that healthcare providers notice when monitoring for changes in neurological status.
Choice C reason: Projectile vomiting may occur with increased ICP, but it is not usually an early sign. It tends to occur after other symptoms such as headache and altered consciousness and is more indicative of significant pressure increases that affect the brainstem.
Choice D reason: Decorticate posturing is a severe sign of brain injury associated with increased ICP but is not an early sign. It indicates significant damage to the brain and is a late and ominous sign in the progression of increased ICP.
Correct Answer is B
Explanation
Choice A reason: Changing the ostomy pouch daily is not necessary and could lead to skin irritation from the frequent removal and application of the adhesive. Ostomy pouches are designed to be worn for several days, and the schedule for changing them can vary based on the type of pouch and individual needs.
Choice B reason: Emptying the ostomy pouch when it is 2/3 full is the correct instruction. This prevents the pouch from becoming too heavy, which could pull on the stoma and cause discomfort or damage. It also reduces the risk of leaks and odors.
Choice C reason: Trimming the opening of the ostomy seal to be 1/2 inch wider than the stoma is incorrect. The opening should be trimmed to match the size of the stoma to provide a secure fit and prevent leakage of the contents onto the skin, which could cause irritation or infection.
Choice D reason: Applying lotion to the peristomal skin when changing the ostomy pouch is not recommended. Lotions or creams can interfere with the adhesive of the ostomy appliance and reduce the effectiveness of the seal. The peristomal skin should be clean and dry to ensure the best adherence of the ostomy appliance.
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