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 D
Explanation
A. Eczema: Eczema is a chronic skin condition characterized by inflammation, redness, and itching. It is not typically caused by bacterial infections and does not present with signs around the mouth and nose.
B. Vitiligo: Vitiligo is a condition characterized by the loss of skin color in patches. It is not caused by bacterial infections and does not typically present with signs around the mouth and nose.
C. Angioedema: Angioedema is swelling beneath the skin, often around the eyes and lips, and is commonly associated with allergic reactions or other triggers. It is not caused by bacterial infections.
D. Impetigo: Impetigo is a bacterial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes bacteria. It commonly presents with red sores or blisters around the mouth and nose, especially in children and the elderly. Therefore, option D, Impetigo, is the correct answer.
Correct Answer is A
Explanation
A. "My belly doesn't hurt anymore."
- This statement is concerning because sudden relief from severe right lower quadrant pain in a child with a history of nausea, vomiting, and suspected appendicitis may indicate a rupture or perforation of the appendix. When the appendix ruptures, there may be a temporary alleviation of pain due to the release of pressure. However, this situation is critical and requires immediate medical attention to prevent further complications such as peritonitis or sepsis.
B. "I am hungry and thirsty."
- While it's normal for a child to feel hungry and thirsty, especially if they have been experiencing nausea and vomiting, this statement is not necessarily concerning on its own. However, in the context of suspected appendicitis and severe right lower quadrant pain, it's important for the child to remain NPO (nothing by mouth) to prevent complications in case surgery is needed.
C. "I'm tired and want to take a nap."
- Feeling tired and wanting to rest is not uncommon, especially if the child has been experiencing discomfort or pain for a prolonged period. While this statement may indicate fatigue, it's not inherently concerning in the context of suspected appendicitis. However, it's important for the nurse to monitor the child's energy level and overall condition.
D. "I am scared and I want to go home."
- It's understandable for a child to feel scared or anxious, particularly when facing a medical procedure such as surgery. While this statement reflects the child's emotions, it doesn't necessarily indicate a change in their medical condition. However, it's important for the nurse to address the child's fears and provide emotional support while ensuring that the child receives appropriate medical care.
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