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.
Keep a padded tongue blade at the client's bedside.
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 {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
The client's pain level should be addressed first based on the principle of prioritizing interventions according to the client's immediate needs and potential severity of the condition. Chest pain, especially when radiating to the left arm, is a concerning symptom that can indicate myocardial ischemia or infarction. It is essential to promptly assess and manage the client's pain to provide relief and potentially mitigate further cardiac damage. In this scenario, the client rates the pain as 7 out of 10, indicating moderate to severe discomfort, which warrants immediate attention.
After addressing the client's pain level, the nurse should focus on the client's ECG results. The ECG findings of tachycardia with ST segment elevation and T wave changes are indicative of myocardial ischemia or infarction. These changes suggest ongoing myocardial damage and require further evaluation and intervention. The ECG results provide crucial information about the client's cardiac status and guide subsequent treatment decisions, such as initiating interventions to restore myocardial perfusion or preparing for invasive procedures like cardiac catheterization.
Correct Answer is B
Explanation
A. While wound infection prevention is important, the elastic bandage primarily addresses edema control.
B. Maintaining an elastic bandage around the residual limb helps to compress soft tissues and minimize edema, promoting healing and aiding in the shaping of the residual limb for future prosthesis fitting.
C. The purpose of the elastic bandage is not related to preventing the client from seeing the surgical site.
D. The elastic bandage is not primarily used to secure sutures; its main purpose is edema control.
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