A nurse is preparing for the admission of a client who has a seizure disorder. Which of the following supplies should the nurse place at the bedside for the client?

NG tube

Tongue blade

Suction machine

Syringe containing lorazepam

Answer and Explanation

The Correct Answer is C

A) NG tube: A nasogastric (NG) tube is not typically required for a client with a seizure disorder unless they have specific feeding or aspiration concerns that require tube feeding. During a seizure, the priority is to ensure airway clearance and prevent injury, not necessarily to provide nutrition through an NG tube.

B) Tongue blade: It is a common myth that tongue blades should be used to prevent a client from biting their tongue during a seizure. However, using a tongue blade can be dangerous as it can cause injury to the mouth or teeth, or even cause choking. The nurse should never attempt to place anything in the client's mouth during a seizure.

C) Suction machine: A suction machine is essential for maintaining airway patency during or after a seizure. Clients with seizure disorders may be at risk for aspiration, and the suction machine can be used to clear secretions from the mouth to prevent choking or aspiration pneumonia. This is the most appropriate supply to place at the bedside.

D) Syringe containing lorazepam: While lorazepam (a benzodiazepine) is sometimes used for acute seizure management, it is not a routine item to have immediately at the bedside unless specifically ordered for emergency seizure intervention. The nurse should follow protocol and administer medications as prescribed, but a syringe of lorazepam is not typically pre-placed at the bedside.

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Correct Answer is B

Explanation

A) Encourage the family to be with the child during mealtimes: While family support during mealtimes can be helpful, it is not the first priority in this situation. The most important step is to understand the child’s dietary habits and challenges in order to create a more targeted and effective approach to addressing the poor dietary intake.

B) Obtain the child’s dietary history: The first step should be to gather information about the child’s dietary history. Understanding what the child is eating, how often, and any potential barriers to proper nutrition (e.g., food preferences, allergies, or cultural practices) is crucial for identifying the root cause of the poor dietary intake. This information will guide the nurse in making appropriate recommendations for improving the child's nutrition.

C) Instruct the family to praise the child when they eat: While positive reinforcement can be a useful strategy, it is not the first step in addressing poor dietary intake. The nurse needs to assess the child’s dietary habits and any possible issues before recommending specific behavioral strategies.

D) Offer the child nutritious snacks between meals: Offering nutritious snacks is a good strategy for improving a child’s nutrition, but it should come after gathering a clear understanding of the child’s eating habits. Without knowing the child’s preferences and needs, it’s better to first assess and identify the cause of the poor intake before recommending snacks.

A. Wait 1 min between 1 suctioning attempts B. Apply intermittent suction for 30 seconds C. Insert the catheter 10 cm (4 in.) D. Apply suction while inserting the catheter.

Correct Answer is C

Explanation

A) Wait 1 min between suctioning attempts: The nurse should wait 20 to 30 seconds between suctioning attempts, not a full minute. Waiting too long between attempts can cause the patient unnecessary distress. The goal is to allow for oxygenation and recovery of the airway in between suctioning attempts.

B) Apply intermittent suction for 30 seconds: Suctioning should be limited to 10 to 15 seconds at a time to prevent hypoxia and damage to the mucous membranes. Applying suction for 30 seconds could lead to complications such as hypoxia, mucosal trauma, and increased risk of infection.

C) Insert the catheter 10 cm (4 in.): This is the correct technique. For an adult client, the catheter should be inserted 10 cm (4 inches) into the airway. Inserting the catheter too far can cause trauma to the airway, while inserting it too shallow may not effectively clear secretions.

D) Apply suction while inserting the catheter: Suction should not be applied while inserting the catheter. Suctioning should only be applied while withdrawing the catheter, not while inserting it, to prevent mucosal trauma and to ensure effective clearance of secretions. Suctioning during insertion could damage the airway and increase discomfort for the client.

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A nurse is preparing for the admission of a client who has a seizure disorder. Which of the following supplies should the nurse place at the bedside for the client?

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