Which nursing action would be appropriate to protect a patient during a seizure? (Select all that apply)
Placing a pad under the patient's head after guiding them to the floor from a standing position
Avoiding placing any objects in the mouth when the patient's teeth are clenched
Guiding the patient to the bed from the floor during a seizure
Turning the patient to one side, having a slightly forward-tilted head
Using supporting pillows for the patient who is on bed
Correct Answer : A,B,D,E
A. Placing a pad under the patient's head after guiding them to the floor from a standing position: This helps to protect the head from injury if the patient falls. However, guiding the patient to the floor should only be done if it is safe and possible to do so without causing further injury.
B. Avoiding placing any objects in the mouth when the patient's teeth are clenched: This prevents the risk of choking or damaging the patient's teeth. It is a common safety measure during seizures.
C. Guiding the patient to the bed from the floor during a seizure: This action is not appropriate during the seizure itself as it may cause injury or disrupt the patient's movement. Instead, the patient should remain in a safe position until the seizure ends.
D. Turning the patient to one side, having a slightly forward-tilted head: This helps to prevent aspiration and facilitates easier breathing during and after the seizure.
E. Using supporting pillows for the patient who is on bed: This helps to protect the patient from injury and provides support, ensuring safety during and after the seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. Placing a high risk for falls armband on the patient: An armband alerts all healthcare providers to the patient's fall risk, helping to ensure appropriate precautions are taken.
B. Checking on the patient once a shift: This is not sufficient; patients on fall precautions should be checked more frequently, such as every hour or according to the facility's protocol, to ensure their safety.
C. Keep the bed in the lowest position: Keeping the bed at its lowest position reduces the risk of injury from falls and helps ensure the patient can easily get in and out of bed.
D. Placing all four side rails in the "up" position: Using all four side rails is not recommended as it can increase the risk of entrapment and may not be effective in preventing falls. Side rails should be used appropriately and in accordance with safety protocols.
E. Maintain call light within reach of the patient: Ensuring the call light is within reach helps the patient call for assistance if needed, which can help prevent falls.
Correct Answer is C
Explanation
A. Grandparents: While grandparents can provide valuable information, parents are typically the primary source of information about a child’s medical history, current symptoms, and behavioral changes.
B. Admitting provider: The admitting provider's role is to assess and diagnose the client. While they provide essential clinical information, they are not the primary source for personal and historical data about the client.
C. Parents: Parents are the most reliable source of information regarding the toddler's medical history, current condition, and any changes in behavior or health. They are most familiar with the child’s day-to-day health and medical background.
D. Medical record: Although the medical record contains important information, it may not have the most recent updates or contextual details that parents can provide. It is important to corroborate the information in the medical record with input from the parents.
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