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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Sore throat: A sore throat is a common and expected finding after extubation due to irritation and mild inflammation of the airway. While discomfort may persist, it does not typically require immediate intervention.

B. SaO2 92%: An oxygen saturation of 92% is slightly lower than normal but is generally acceptable in most patients following extubation. Close monitoring is necessary, but immediate intervention is not required unless the saturation continues to decline.

C. Stridor: Stridor is a high-pitched, harsh sound caused by upper airway obstruction, often due to post-extubation laryngeal edema. This is a medical emergency requiring immediate intervention, such as administration of nebulized epinephrine, corticosteroids, or reintubation if severe airway compromise occurs.

D. Rhonchi: Rhonchi are low-pitched, coarse lung sounds caused by mucus or secretions in the airways. This finding may indicate the need for suctioning or respiratory therapy but does not require urgent intervention compared to stridor.

A. A palpable thrill at the fistula site B. Hyperglycemia C. Altered mental status D. Decrease in weight

Correct Answer is C

Explanation

A. A palpable thrill at the fistula site: A palpable thrill is a normal finding that indicates proper blood flow through the arteriovenous fistula. The absence of a thrill would be concerning, as it may suggest clotting or dysfunction of the vascular access.

B. Hyperglycemia: Hemodialysis does not typically cause hyperglycemia. Clients with diabetes may experience fluctuations in blood glucose levels, but dialysis itself is more commonly associated with hypoglycemia due to the removal of glucose from the bloodstream.

C. Altered mental status: Neurological changes such as confusion, restlessness, or decreased responsiveness may indicate dialysis disequilibrium syndrome (DDS). This complication results from rapid fluid and solute shifts, leading to cerebral edema. It is a serious condition requiring immediate intervention.

D. Decrease in weight: A decrease in weight following hemodialysis is expected due to fluid removal. Clients are weighed before and after dialysis to monitor fluid balance, and weight loss after treatment indicates effective fluid removal rather than a complication.

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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.)

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