A nurse on the medical-surgical unit is caring for a client who has a seizure disorder.

Which of the following interventions should the nurse include in the plan of care?

Pad the upper two side rails of the client's bed.

Maintain peripheral IV access.

Teach assistive personnel how to apply restraints.

Keep a padded tongue blade at the client's bedside.

Answer and Explanation

The Correct Answer is A

A)   Padding the upper two side rails of the client's bed helps prevent injury during a seizure by reducing the risk of head trauma.
B)   Maintaining peripheral IV access may not directly address the client's safety during a seizure.
C)   Teaching assistive personnel to apply restraints is not appropriate for managing seizures and may not be indicated unless other safety measures have failed.
D)   Keeping a padded tongue blade at the client's bedside is not necessary and may not be safe if the client experiences a seizure.

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Correct Answer is A

Explanation

A. The client's dyspnea and elevated blood pressure may indicate fluid volume overload. Slowing the infusion rate and notifying the provider are appropriate actions.
B. Lowering the head of the bed may help with dyspnea but does not address the underlying cause of fluid overload.
C. Administering corticosteroids is not indicated based on the client's symptoms and situation.
D. Changing the infusion to lactated Ringer's may be appropriate, but slowing the infusion rate and assessing the client further are the priority actions.

A. Morse Fall Risk scale B. Braden scale C. Pain assessment D. Neurovascular assessment

Correct Answer is D

Explanation

A) The Morse Fall Risk scale assesses the risk of falls in hospitalized patients but is not the priority for a postoperative client with an ORIF.
B) The Braden scale assesses the risk of pressure ulcers and is not the priority for a postoperative client with an ORIF.
C) Pain assessment is important but may not be the priority compared to assessing neurovascular status, especially immediately postoperatively.
D) The neurovascular assessment, including circulation, sensation, and movement, is crucial for early detection of complications such as compartment syndrome or impaired blood flow.

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A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care?

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A nurse on the medical-surgical unit is caring for a client who has a seizure disorder.

Which of the following interventions should the nurse include in the plan of care?