You have a patient who has a brain tumor and is at risk for seizures. In the patient's plan of care you incorporate seizure precautions. Select the 3 choices below for all the proper steps to take in initiating seizure precautions. (Select All that Apply.)
Bed in highest position
Remove restrictive objects or clothing from patients’ body
Remove all pillows from the patient's head
Oxygen and suction at bedside
Padded bed rails
Correct Answer : B,D,E
A. Bed in highest position:
The height of the bed is not directly related to seizure precautions.
B. Remove restrictive objects or clothing from patients’ body:
This is important to prevent injury during a seizure episode.
C. Remove all pillows from the patient's head:
While it's generally a good practice to remove pillows to prevent suffocation or obstruction, it's not specifically related to seizure precautions.
D. Oxygen and suction at bedside:
Oxygen and suction should be readily available to support the patient's respiratory status and clear any secretions or vomit during or after a seizure.
E. Padded bed rails:
Padded bed rails can help prevent injury if the patient thrashes or moves violently during a seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increase in appetite: Otitis media, an infection or inflammation of the middle ear, typically causes discomfort and pain in infants. As a result, they may experience a decrease in appetite rather than an increase.
B. Tugging on the affected ear lobe: Tugging or pulling on the affected ear lobe is a common sign of ear pain in infants with otitis media. It occurs because the pain from the middle ear extends to the outer ear canal.
C. Erythema and edema of the affected auricle: Otitis media primarily affects the middle ear, so erythema (redness) and edema (swelling) are not typically observed on the outer ear (auricle). Instead, these symptoms are more commonly seen in external ear infections, such as otitis externa.
D. Bluish-green discharge from the ear canal: Bluish-green discharge from the ear canal is not a typical finding in otitis media. It may suggest a secondary bacterial infection or another underlying condition, but it is not a characteristic feature of otitis media.
Correct Answer is B
Explanation
A. Ridged abdomen - This finding is not typically associated with Hirschsprung disease. Instead, the abdomen may appear distended or bloated due to the accumulation of stool in the colon.
B. Ribbonlike, foul-smelling stools - This is a characteristic finding in Hirschsprung disease. Because the affected portion of the colon lacks nerve cells (ganglion cells) responsible for peristalsis, stool movement is impaired, leading to the passage of narrow, ribbonlike stools. These stools may also have a foul odor due to bacterial overgrowth in the affected area.
C. Projectile vomiting - Projectile vomiting is not a common finding in Hirschsprung disease. It is more commonly associated with conditions such as pyloric stenosis or gastroesophageal reflux.
D. Chronic hunger - Chronic hunger is not a typical finding in Hirschsprung disease. Instead, affected infants may experience feeding difficulties, constipation, and failure to thrive due to the obstruction of stool in the colon. They may also exhibit symptoms such as abdominal distention, vomiting, and refusal to feed.
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