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.

Answer and Explanation

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

Explanation

A. A client who has had prolonged diarrhea:

Prolonged diarrhea is not typically associated with an increased risk of aspiration during eating.

B. A client who has lactose intolerance:

Lactose intolerance primarily affects the ability to digest lactose-containing foods and does not directly increase the risk of aspiration.

C. A client who has had radiation therapy for head and neck cancer:

Radiation therapy to the head and neck can cause damage to the structures involved in swallowing, increasing the risk of aspiration.

D. A client who has had a stroke:

Stroke can affect the coordination of swallowing muscles, leading to dysphagia (difficulty swallowing) and an increased risk of aspiration.

E. A client who is 4 hr postoperative following a leg amputation under general anesthesia:

Postoperative clients under general anesthesia may experience impaired protective airway reflexes, making them prone to aspiration. It's important to monitor these clients closely during the initial recovery period.

A. "I'm sure your wife will begin to feel better soon." B. "It must be very difficult for you to see your wife in pain." C. "I wish there was more that I could do to relieve your wife's pain, too." D. "We're doing everything we can to keep your wife comfortable."

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk for aspiration while eating? (Select all that apply.)

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

Explanation

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Correct Answer is C

Explanation

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