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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Related Questions
Correct Answer is B
Explanation
A. Position the client on her side:
While placing the client on her side is important, especially if there is a risk of aspiration during the seizure, maintaining the airway takes precedence as the priority action.
B. Maintain the patency of the client's airway:
This is the correct answer. Ensuring the airway is open and unobstructed is the immediate priority during a seizure. This involves positioning the client to prevent airway compromise and potentially using suction if necessary.
C. Identify the poison the client ingested:
While identifying the poison is important for subsequent management, it is not the immediate priority during an active seizure. The focus is on stabilizing and ensuring the client's safety.
D. Measure the client's blood pressure:
Monitoring vital signs, including blood pressure, is an essential aspect of care, but it is not the immediate priority during an active seizure. Airway management takes precedence to prevent complications such as hypoxia.
Correct Answer is A
Explanation
A. Discontinuing the existing IV infusion is the priority when signs of infection or inflammation are present at the site. This action helps prevent the spread of infection and allows for a thorough assessment of the site.
B. Inserting an IV catheter in the opposite extremity is not the first step. Before considering a new IV site, it's crucial to address the issue with the current site. Starting a new IV line before addressing the potential infection could lead to further complications.
C. Applying warm, moist compresses to the site is not the first action. While warm compresses can be used to promote blood flow and comfort, the priority is to discontinue the current infusion and assess for infection or inflammation.
D. Elevating the extremity is not the first action in response to signs of infection or inflammation at an IV site. The priority is to discontinue the infusion and assess the site for potential complications.
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