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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Disorientation in an older adult after taking lorazepam could indicate an adverse reaction or an excessive sedative effect. It's crucial to report this immediately as it may signify an overdose or an adverse reaction to the medication. Older adults are more sensitive to the sedative effects of benzodiazepines, and disorientation can indicate potential serious side effects.
B. Anorexia (loss of appetite) is a possible side effect of lorazepam but is not typically considered an urgent or immediate concern unless it leads to severe dehydration or other complications.
C. Increased anxiety could potentially occur due to paradoxical reactions to benzodiazepines; however, it's not typically considered an urgent or immediate concern unless it's severe or distressing to the client.
D. Blurred vision is a common side effect of lorazepam and other benzodiazepines. While it should be monitored and reported, it might not be considered an urgent concern unless it's significantly affecting the client's ability to function or is accompanied by other severe symptoms.
Correct Answer is C
Explanation
A. "I'm sure your wife will begin to feel better soon."
This response is somewhat reassuring but may come across as dismissive or overly optimistic. It doesn't acknowledge the partner's feelings or offer support.
B. "It must be very difficult for you to see your wife in pain."
This response acknowledges the partner's emotions and shows empathy. While it recognizes the difficulty the partner is experiencing, it doesn't directly address the partner's desire to do something to help the wife.
C. "I wish there was more that I could do to relieve your wife's pain, too."
This response directly empathizes with the partner's wish to help the wife, expressing a shared concern. It conveys a sense of teamwork between the nurse and the partner, fostering a supportive connection.
D. "We're doing everything we can to keep your wife comfortable."
This response provides information about the actions being taken by the medical team but may not directly address the partner's expressed desire to contribute or alleviate the wife's pain.
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