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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Regresses to an earlier developmental level:
While it is possible for a child to show some regression in behavior when faced with a stressful situation such as a sibling’s illness, school-age children are typically able to understand more complex concepts. Regression to an earlier developmental stage is more common in younger children (preschool-age) rather than school-age children, who are more likely to express their emotions in other ways.
B) Alienates himself from his peers:
While the child may experience feelings of isolation or withdrawal due to the stress of a sibling’s terminal illness, alienation from peers is not the most typical or immediate response for a school-age child. It is more common for children of this age to seek comfort and support from peers, though they may struggle with how to discuss their feelings.
C) Believes that his brother's death will be reversible:
At a school-age level, children generally begin to understand the permanence of death. While younger children may have magical thinking that could lead them to believe the death of a loved one could be reversible, this is not the expected response for a school-age child. By this age, children typically comprehend that death is final, although they may struggle with the emotional aspect of it.
D) Believes his bad behavior is causing his brother's death:
This response is the most typical for a school-age child. At this stage, children often have a sense of responsibility for events around them and may develop feelings of guilt or magical thinking, where they believe their actions or behavior contributed to the illness or death of a loved one. This belief is part of the normal coping process but needs to be addressed in counseling or with support from caregivers to help the child understand the situation and alleviate any misplaced guilt.
Correct Answer is C
Explanation
A) Assists the client to the bathroom every 2 hr: This action is appropriate as regular assistance with toileting can help prevent falls by ensuring the client is not trying to get up unassisted when they need to use the bathroom. Assisting every 2 hours is reasonable to minimize the risk of falls, especially in clients who are at risk.
B) Clears furniture from the path leading to the bathroom: This action is correct as it reduces environmental hazards that could contribute to a fall. Ensuring that the path to the bathroom is free from obstacles is a key safety measure for clients at risk for falls.
C) Raises all four side-rails on the client's bed: This is an action the nurse should intervene on. Raising all four side rails is considered a restraint in many settings and could increase the risk of injury if the client tries to climb over or becomes entangled. It can also contribute to a feeling of entrapment or confusion. Side rails should only be used according to specific protocols and when necessary for safety, not as a blanket solution for fall prevention.
D) Locks the wheels on the client's bed: Locking the wheels on the bed is an appropriate safety measure. Ensuring the bed is stationary when the client is in it reduces the risk of accidental movement and potential falls.
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