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 A
Explanation
A. Stop the infusion: Acute hemolytic reactions can occur within minutes of starting a transfusion and are life-threatening. Symptoms such as chills, lower back pain, and nausea indicate a potential reaction, requiring immediate discontinuation of the transfusion to prevent further hemolysis and organ damage.
B. Collect a urine sample: A urine sample helps detect hemoglobinuria, a sign of red blood cell destruction, but it is not the priority. The infusion must be stopped first to prevent further complications before obtaining a urine sample for analysis.
C. Check the client's vital signs: Monitoring vital signs is essential, but the priority is stopping the transfusion to halt the reaction. Vital signs should be checked after discontinuing the infusion to assess the severity of the reaction and guide further interventions.
D. Administer oxygen to the client: Oxygen may be needed if respiratory distress occurs, but stopping the transfusion is the first step to prevent continued exposure to the incompatible blood product. Oxygen therapy should be implemented based on the client's condition after discontinuing the infusion.
Correct Answer is ["37.5"]
Explanation
Volume = Desired Dose / Available Concentration
Available: 12.5 mg / 5 mL
=2.5 mg/mL
Volume in mL = 0.5 oz × 30 mL/oz = 15 mL
Desired Dose = Volume (mL) × Available Concentration (mg/mL)
= 15 mL × 2.5 mg/mL
Desired Dose = 37.5 mg
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