The nurse is caring for a patient who was admitted for seizures. All of the following precautions should be taken to promote a safe environment except which?

Have the client use the call light if they need to get up

Pad the side rails of the client’s bed

Ensure the lights in the room are as bright as possible at all times

Avoid over stimulation and excessive activity in the client’s room

Answer and Explanation

The Correct Answer is C

A. "Have the client use the call light if they need to get up":
This is an appropriate precaution to promote safety for a patient who has seizures. It is important to encourage patients to call for assistance before getting up, especially if they are at risk for seizures. Having the patient use the call light ensures that they do not try to walk or move without supervision, which could lead to falls or injury.

B. "Pad the side rails of the client’s bed":
This is also an appropriate precaution. Padding the side rails of the bed is a common safety measure for patients who are at risk for seizures. The padding helps prevent injury if the patient moves during a seizure. Side rails should be raised during a seizure to prevent the patient from falling out of bed, but the risk of injury from the side rails themselves is minimized with padding.

C. "Ensure the lights in the room are as bright as possible at all times":
This is not an appropriate precaution. Bright lights in the room could potentially cause overstimulation, which may be a trigger for seizures in some patients. In addition, bright lights could contribute to discomfort and anxiety. Instead, the room should be kept at a comfortable, calm lighting level to help reduce stress and minimize the risk of triggering a seizure.

D. "Avoid over stimulation and excessive activity in the client’s room":
This is an appropriate precaution. Avoiding overstimulation is important for patients with seizure disorders. Excessive noise, bright lights, or other sources of stress or agitation could provoke a seizure. A calm, quiet environment helps to promote safety and reduce the risk of a seizure occurring.

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Correct Answer is C

Explanation

A) "HDL cholesterol 60 mg/dL":
This is not a risk factor. High-density lipoprotein (HDL) is often referred to as "good cholesterol" because it helps remove excess cholesterol from the bloodstream, lowering the risk of atherosclerosis and cardiovascular disease. An HDL level of 60 mg/dL is considered protective against cardiovascular disease, as higher levels of HDL are associated with a lower risk of heart disease.

B) "Total cholesterol 210 mg/dL":
This is not a significant risk factor on its own. While total cholesterol above 200 mg/dL is a general indicator for cardiovascular risk, it is not as important as the breakdown of individual lipid components (HDL, LDL). A total cholesterol of 210 mg/dL is only slightly above the ideal less than 200 mg/dL, and on its own, it is not a strong indicator of increased cardiovascular risk without considering other factors like LDL and HDL levels.

C) "LDL cholesterol 110 mg/dL":
. Low-density lipoprotein (LDL) is known as "bad cholesterol" because it can lead to the buildup of plaque in the arteries, increasing the risk for atherosclerosis, heart disease, and stroke. An LDL level of 110 mg/dL is considered to be above optimal. For individuals at risk for cardiovascular disease, the target LDL cholesterol level is usually less than 100 mg/dL, and for those with high risk, it may be less than 70 mg/dL. Therefore, this level of LDL cholesterol places the client at increased risk for cardiovascular disease.

D) "Hgb A1C 5.3%":
This is not a risk factor. An Hgb A1C of 5.3% is within the normal range for glycemic control. The American Diabetes Association defines normal A1C as below 5.7%. A1C levels between 5.7% and 6.4% are considered pre-diabetes, and a level of 6.5% or higher indicates diabetes. A normal A1C level indicates no significant elevated blood glucose, which would be a risk factor for cardiovascular disease.

A. Early ambulation can help keep your lungs expanded and prevent pneumonia B. Early ambulation is one part of preventing blood clots from forming in your legs C. Early ambulation usually delays wound healing and increases the risk wound infection D. Early ambulation can help your bladder and bowels recover from the anaesthesia

Correct Answer is C

Explanation

A. "Early ambulation can help keep your lungs expanded and prevent pneumonia":
This statement is correct. Early ambulation is beneficial for respiratory function as it helps to keep the lungs expanded, encouraging deeper breaths and better oxygenation. This can help prevent complications like pneumonia and atelectasis, which are common after surgery due to immobility and anesthesia.

B. "Early ambulation is one part of preventing blood clots from forming in your legs":
This statement is also correct. Early ambulation is an important measure in preventing deep vein thrombosis (DVT) and pulmonary embolism (PE), which are common postoperative complications. Movement and walking promote circulation, reducing the risk of blood clots forming in the legs.

C. "Early ambulation usually delays wound healing and increases the risk of wound infection":
This statement is incorrect. Early ambulation does not delay wound healing or increase the risk of infection. In fact, early movement can help improve circulation, which is crucial for wound healing and tissue repair. Gentle movement and ambulation typically have positive effects on wound healing by promoting blood flow to the surgical site. However, patients should avoid excessive strain or stress on the wound to prevent dehiscence or other complications.

D. "Early ambulation can help your bladder and bowels recover from the anesthesia":
This statement is correct. Early ambulation helps stimulate gastrointestinal and urinary systems, which may be sluggish after anesthesia. Walking can encourage the return of normal bowel and bladder function by promoting peristalsis and helping to prevent constipation or urinary retention, both of which can be common after surgery.

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The nurse is caring for a patient who was admitted for seizures. All of the following precautions should be taken to promote a safe environment except which?

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