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. Place new linen on the client's bed every other day: While changing linen regularly is important for maintaining cleanliness and preventing infection, waiting every other day may not be sufficient for a client with burns, especially if there is wound drainage or soiling. Linens should be changed more frequently, ideally daily or as needed, to ensure cleanliness and prevent the spread of infection.
B. Change gloves between sites when providing wound care to multiple wounds: This is a correct action. Changing gloves between sites when providing wound care helps prevent the spread of infection from one wound to another. It reduces the risk of cross-contamination and helps maintain a sterile environment during wound care procedures.
C. Change the dressing on infected wounds first: This is incorrect. Dressings on infected wounds should be changed promptly to prevent the spread of infection. However, changing the dressing on infected wounds first may lead to contamination of other wound sites if proper precautions are not taken. It's important to follow proper infection control procedures, including changing gloves between wound sites and using aseptic technique.
D. Monitor vital signs every 4 hr: Monitoring vital signs is important for assessing the client's overall condition, but it is not directly related to preventing infection. Vital signs may indicate signs of infection, such as fever or increased heart rate, but they do not prevent infection on their own. Other measures, such as wound care and infection control practices, are more directly related to preventing infection in clients with burns.
Correct Answer is A
Explanation
A. No treatment is necessary, the fluid is reabsorbing normally:
- This option suggests that the hydrocele is resolving spontaneously, which is often the case in infants. The physician may choose to observe the hydrocele over time as it is likely to resolve without intervention.
B. Keeping the infant in a flat, supine position until the fluid is gone:
- This option does not address the underlying cause of the hydrocele and is not a standard treatment recommendation. Additionally, positioning changes are unlikely to affect the resolution of the hydrocele.
C. Referral to a surgeon for repair:
- Surgical repair may be considered if the hydrocele persists beyond a certain age or if it causes discomfort or complications. However, it is typically not recommended in infants unless the hydrocele persists beyond infancy or causes other issues.
D. Massaging the groin area twice a day until the fluid is gone:
- Massaging the groin area is not a recommended treatment for hydrocele and may not be effective in resolving the condition. Additionally, manipulating the scrotum may cause discomfort or injury to the infant.
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