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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. "I know this can be embarrassing. I have kids myself so I understand, and it doesn't bother me."

This response acknowledges the child's feelings and reassures the parents that bedwetting is a common occurrence, especially during hospitalization. It also demonstrates empathy by sharing a personal experience. However, it may not address the parents' concerns about their child's bedwetting or provide information on how to manage it.

B. "Children who are hospitalized often regress. The toileting skills will return when your child is feeling better."

This response provides an explanation for the bedwetting incident, reassuring the parents that it is a common response to hospitalization and will likely resolve once the child feels better. It offers support and normalization of the behavior, which can help alleviate the parents' concerns.

C. "I will discuss your child's loss of bladder control with the provider."

This response indicates that the nurse will address the issue with the healthcare provider, which is appropriate if further evaluation or intervention is needed. However, it may not directly address the parents' concerns or provide immediate reassurance.

D. "Why is she wetting the bed in the hospital? She must wet the bed at home."

This response may come across as accusatory or judgmental, which can increase parental anxiety or guilt. It does not provide reassurance or support to the parents and does not address the child's immediate needs.

A. Wheezing B. Rigid abdomen C. Pallor D. Weight loss E. Vomiting

Correct Answer is ["A","D","E"]

Explanation

A. Wheezing: Wheezing is a common symptom associated with asthma, which can be exacerbated by gastroesophageal reflux (GER) in infants. GER occurs when stomach contents flow back into the esophagus, leading to irritation and inflammation of the airways. This inflammation can cause wheezing sounds during breathing, especially if the refluxed material reaches the lower respiratory tract.

B. Rigid abdomen: While gastroesophageal reflux (GER) primarily affects the upper gastrointestinal tract, it typically does not cause a rigid abdomen. A rigid abdomen may indicate other underlying gastrointestinal issues such as bowel obstruction, intussusception, or peritonitis. These conditions are not typically associated with GER in infants.

C. Pallor: Pallor, or paleness of the skin, is not a common symptom of gastroesophageal reflux (GER) in infants. GER primarily affects the upper gastrointestinal tract and is characterized by symptoms such as spitting up, regurgitation, and irritability. Pallor may be indicative of other health issues such as anemia or circulatory problems but is not directly related to GER.

D. Weight loss: Weight loss can occur in infants with gastroesophageal reflux (GER) if frequent vomiting leads to inadequate intake of nutrients. However, it is not a direct symptom of GER itself. Infants with GER may experience feeding difficulties, irritability, and discomfort associated with feeding, which can contribute to poor weight gain over time if not managed effectively.

E. Vomiting: Vomiting is a common symptom of gastroesophageal reflux (GER) in infants. It occurs when stomach contents flow back up into the esophagus and sometimes out of the mouth. Infants with GER may spit up or vomit frequently after feeding or during burping, which can lead to discomfort and irritability. Vomiting may also contribute to poor weight gain and nutritional deficiencies if not managed effectively.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 4-year-old child who had an incident of bedwetting during hospitalization. The child's parents expresses concern about the incident. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is collecting data from an infant who has gastroesophageal reflux. Which of the following findings should the nurse expect? (Select the 3 that apply.)

Correct Answer is ["A","D","E"]

Explanation

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