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. Maintain a saline-lock:
While maintaining a saline lock is important for ensuring vascular access in case of emergency, it is not the priority action in caring for a child with acute glomerulonephritis. Monitoring fluid balance and electrolyte levels may be necessary, but the immediate priority is to educate the parents about potential complications.
B. Check the child's weight daily:
Monitoring daily weight is crucial in acute glomerulonephritis, as it helps assess fluid balance and detect early signs of fluid retention or worsening kidney function, which are key concerns in this condition. This makes it a priority action.
C. Place the child on a no-salt-added diet:
Dietary modifications, including reducing salt intake, may be recommended for managing acute glomerulonephritis. However, it is not the priority action at this stage.
D. Educate the parents about potential complications:
Parental education is important for long-term management and understanding of the condition, but it is not the most immediate priority in the acute phase of the illness.
Correct Answer is A
Explanation
A. Pain management is critical for burn care, especially before activities like physical therapy that can be painful. Administering pain medication 30 minutes before therapy helps ensure the child is more comfortable and able to participate effectively in rehabilitation. This is a recommended intervention.
B. While involving the child in decisions about their care can promote autonomy and improve adherence, the schedule for burn care and therapy should be based on medical needs and healing processes rather than the child's preference. Care schedules should be designed to optimize healing and manage pain effectively.
C. Provide low-calorie snacks:Burn patients typically have increased nutritional needs due to the high metabolic demands of healing. High-calorie, protein-rich snacks are usually recommended to support wound healing and overall recovery, rather than low-calorie options.
D. Maintain medical asepsis during dressing changes: For burn care, maintaining sterile technique is critical to prevent infection. Medical asepsis is generally not sufficient; sterile technique is required for dressing changes to reduce the risk of infection.
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