A nurse on a medical unit is caring for a client who requires seizure precautions. Which of the following interventions should the nurse contribute to the client's plan of care?
Keep the lights on when the client is sleeping.
Restrain the client as soon as seizure activity begins.
Have a padded tongue depressor available at the bedside.
Keep the client's bed in the lowest position.
The Correct Answer is D
A. Keeping the lights on when the client is sleeping is not a standard intervention for seizure precautions. In fact, it's generally recommended to create a quiet and low-stimulus environment for clients with seizure disorders.
B. Restraining the client as soon as seizure activity begins is not recommended. Restraints can lead to injuries and complications during a seizure. It is essential to allow the client to move and prevent injury by removing harmful objects from the vicinity.
C. Having a padded tongue depressor available at the bedside is not a standard intervention for seizure precautions. In the event of a seizure, the priority is to keep the client safe, protect their head, and ensure a clear airway. Placing objects in the mouth is not recommended and can lead to injury.
D. Keeping the client's bed in the lowest position is a safety measure to prevent injuries during a seizure. It reduces the risk of falling from a significant height in case of a seizure episode.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. It is not permissible because the provider should disclose laboratory results or findings to a client:
While it is true that the provider should disclose laboratory results or findings to the client, the nurse, in this case, should not be accessing the information on behalf of the sibling without proper authorization.
B. It is permissible because the client's sibling made the request:
Even if the sibling made the request, accessing a client's health information without proper authorization is a violation of privacy and confidentiality.
C. It is permissible because the sibling has paid for the service:
Payment for services does not automatically grant access to health information. Protected health information (PHI) is subject to privacy laws, and access should be granted only to those authorized to receive it.
D. It is not permissible because there is no nurse-client relationship between the sibling and nurse:
This is the correct explanation. The nurse should not access a client's health information, even if it is a family member, without proper authorization. The absence of a nurse-client relationship with the sibling does not justify accessing the client's health information.
Correct Answer is D
Explanation
A. Provide client care as assigned:
While it is essential to be flexible and adaptable, patient safety is a priority. If the nurse is not familiar with certain skills or techniques and believes it could compromise patient safety, blindly providing care may not be the best option.
B. Make a formal complaint to the nursing manager:
Making a formal complaint should not be the initial step. It is better to explore other options before escalating the situation to a higher level.
C. Request the charge nurse to modify the assignment:
This is a reasonable option. The nurse can communicate concerns to the charge nurse and request modifications to the assignment based on their skills and competency.
D. Ask another nurse to trade assignments:
This is the most immediate and practical solution. If there's another nurse available who is more familiar with the required skills, trading assignments can ensure that the patient receives appropriate care from a nurse with the necessary expertise.
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