A nurse is planning care for a client who is experiencing seizures secondary to meningitis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
Place a tongue blade at the bedside.
Dim the overhead lights.
Assist the client to ambulate every 4 hr.
Apply a warming blanket.
Have suction equipment at the bedside.
Correct Answer : B,E
A. Place a tongue blade at the bedside: Keeping a tongue blade at the bedside is not recommended because attempting to insert an object into the mouth during a seizure can cause injury to the teeth, gums, or airway. Instead, the focus should be on maintaining a safe environment and protecting the client from harm.
B. Dim the overhead lights: Meningitis can cause photophobia, or sensitivity to light, which can worsen discomfort and potentially trigger seizures. Dimming the lights helps reduce sensory stimulation and promotes comfort, decreasing the risk of further neurological agitation.
C. Assist the client to ambulate every 4 hr: Clients experiencing seizures should have activity restrictions to prevent falls and injuries. Ambulation should be supervised and only encouraged once the client is stable. Frequent rest is preferred to minimize exhaustion, which can contribute to seizure activity.
D. Apply a warming blanket: Meningitis can cause fever, but applying a warming blanket is not appropriate unless the client is experiencing hypothermia. Fever management typically involves antipyretics and cooling measures, such as tepid sponge baths or light clothing, rather than warming interventions.
E. Have suction equipment at the bedside: During a seizure, excessive secretions or impaired airway protection can lead to aspiration. Having suction equipment readily available allows for quick clearance of the airway once the seizure subsides, reducing the risk of respiratory complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","F","G","H","I","J"]
Explanation
- Open wound on right foot with purulent drainage: A non-healing wound with purulent drainage suggests infection, which is a major concern in clients with hyperglycemia. Poor wound healing is common in diabetes due to impaired circulation and immune function.
- Frequent urination, increased thirst, and unexplained 4.5 kg (10 lb) weight loss: Classic symptoms of hyperglycemia and possible diabetes mellitus. Polyuria and polydipsia result from osmotic diuresis due to high blood glucose levels, while unexplained weight loss may indicate the body breaking down fat and muscle for energy.
- Temperature 38.3° C (100.9° F): Fever indicates a possible systemic infection. In diabetic clients, infections can progress rapidly and lead to complications such as cellulitis, osteomyelitis, or sepsis.
- Heart rate 104/min: Tachycardia may be a response to fever, dehydration, or underlying infection. Persistent tachycardia could indicate worsening sepsis or hemodynamic instability.
- Blood pressure 98/74 mm Hg: While not critically low, this blood pressure is on the lower end and could indicate early signs of dehydration from polyuria or systemic infection.
- Blood glucose 250 mg/dL: Significantly elevated blood glucose suggests poor glycemic control, increasing the risk of infection, delayed wound healing, and diabetic ketoacidosis (DKA) if it continues to rise.:
- Respiratory rate 18/min: A normal respiratory rate does not indicate respiratory distress or metabolic compensation.
- Oxygen saturation 97% on room air: Oxygenation is within the normal range, suggesting no immediate hypoxia.
- WBC count 9,500/mm³: Within the normal range, although an infection may still be present given the fever and purulent wound drainage.
- Triiodothyronine (T3) 200 mg/dL: Within normal limits, ruling out thyroid dysfunction as a cause of symptoms.
- BMI 27: Slightly overweight but not directly contributing to the acute condition.
Correct Answer is B
Explanation
A. Fasting blood glucose level: This test provides a snapshot of the client's blood glucose at a single point in time, typically after an overnight fast. While useful for daily monitoring, it does not reflect long-term glycemic control.
B. Glycosylated hemoglobin level: Hemoglobin A1c measures average blood glucose levels over the past 2 to 3 months, making it the most reliable indicator of long-term glycemic control. A target level below 7% is recommended for most individuals with diabetes.
C. Postprandial blood glucose level: This test evaluates blood sugar levels after meals but only provides short-term information about glucose fluctuations rather than an overall picture of glycemic control.
D. Oral glucose tolerance test results: This test is primarily used to diagnose diabetes and gestational diabetes rather than to monitor long-term control in individuals already diagnosed with diabetes.
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