A nurse working on a medical unit is caring for a patient who is placed on seizure precautions. Which of the following interventions should the nurse include in the patient's plan of care?
Keep a padded tongue blade available at the patient's bedside.
Place the patient's bed in the high position.
Keep the lights on when the patient is sleeping.
Obtain IV access.
The Correct Answer is D
A. Incorrect. Never insert anything into a seizing patient's mouth, as it can cause injury.
B. Incorrect. The bed should be in the lowest position to prevent falls.
C. Incorrect. Keeping lights on is unnecessary and can cause sensory overstimulation.
D. Correct. IV access is important in case emergency medications (e.g., lorazepam) are needed during a seizure.
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Related Questions
Correct Answer is C
Explanation
A. Encourage the patient to ask for assistance. – Patients with Alzheimer's often forget to ask for help, making this an unreliable safety measure.
B. Keep the call light near the patient. – The patient may not remember to use the call light.
C. Place the patient in a room close to the nurses' station. – Correct Answer. This allows frequent observation and quick intervention to prevent falls.
D. Remind the patient to walk with someone for support. – Reminders may not be effective due to memory impairment.
Correct Answer is A
Explanation
A. Applying a sequential compression device. – Correct Answer. SCDs help prevent venous stasis, reducing the risk of DVT in immobile patients.
B. Administering an antifibrinolytic agent. – Incorrect. Antifibrinolytics promote clot formation and are used for bleeding disorders, not DVT prevention.
C. Placing the patient on a fluid restriction. – Incorrect. Adequate hydration is important to prevent blood viscosity and clot formation.
D. Assisting the patient with passive ROM exercises. – Incorrect. Passive ROM helps circulation, but SCDs provide more effective DVT prevention.
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