A nurse is reviewing the medical records of a group of clients. For which of the following clients should the nurse implement seizure precautions?

A client who is experiencing withdrawal from oxycodone.

A client who is experiencing withdrawal from diazepam.

A client who has a low lithium level.

A client who has a low imipramine level.

Answer and Explanation

The Correct Answer is B

A reason: A client who is experiencing withdrawal from oxycodone. While withdrawal from oxycodone can cause significant symptoms, it is not typically associated with seizures. Other withdrawal symptoms, such as anxiety and agitation, are more common.

B reason: A client who is experiencing withdrawal from diazepam. Withdrawal from diazepam, a benzodiazepine, can lead to seizures, especially if the drug is stopped abruptly. Seizure precautions are necessary to manage this risk and ensure the client's safety.

C reason: A client who has a low lithium level. A low lithium level typically indicates subtherapeutic dosing rather than an immediate risk of seizures. Monitoring for mood symptoms is more relevant in this context.

D reason: A client who has a low imipramine level. Low levels of imipramine, an antidepressant, do not generally pose a risk for seizures. The focus should be on managing depressive symptoms and adjusting medication as needed.

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Correct Answer is ["A","C","D"]

Explanation

A reason: Lack of eye contact. Children with autism spectrum disorder (ASD) often exhibit reduced or lack of eye contact, which can be a key indicator of social communication difficulties associated with ASD.

B reason: Inability to play quietly. While some children with autism might exhibit hyperactive behavior, an inability to play quietly is not a specific characteristic of ASD. It can be seen in various conditions, including attention deficit hyperactivity disorder (ADHD).

C reason: Constant spinning of a toy. Repetitive behaviors, such as spinning objects, are common in children with ASD. These behaviors provide sensory input and can be calming for the child.

D reason: Withdrawal from physical contact. Children with ASD often withdraw from physical contact due to sensory sensitivities. They might find certain touches uncomfortable or overwhelming.

E reason: Repeated voicing in clothes. Repeating phrases or sounds, known as echolalia, is common in ASD, but "repeated voicing in clothes" does not accurately describe this behavior. It seems like a typographical error.

A. Document the client's behavior once every hour. B. Keep the client in restraints until the prescription expires. C. Conduct a debriefing regarding the client with the unit staff. D. Request an evaluation of the client within 12 hours of application of restraints.

Correct Answer is C

Explanation

A reason: Document the client's behavior once every hour. While documenting the client's behavior is important, it should be done more frequently than once every hour. Monitoring should be continuous to ensure the client's safety.

B reason: Keep the client in restraints until the prescription expires. Restraints should be used for the shortest duration necessary to ensure safety, not just until the prescription expires. Regular assessments are needed to determine if they can be removed earlier.

C reason: Conduct a debriefing regarding the client with the unit staff. Debriefing with the unit staff helps ensure everyone is informed about the client's condition, the reasons for using restraints, and the plan for ongoing care. This promotes a team approach to managing the client's behavior.

D reason: Request an evaluation of the client within 12 hours of application of restraints. An evaluation should be conducted much sooner than 12 hours, typically within an hour of applying restraints, to assess the client's physical and mental status and determine if continued use is justified.

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A nurse is reviewing the medical records of a group of clients. For which of the following clients should the nurse implement seizure precautions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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