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. Monitor the client's hemoglobin level: Monitoring the client's hemoglobin level is not relevant during a seizure. Seizures typically do not directly affect hemoglobin levels, so this action is not appropriate.
B. Restrain the client's extremities: Restraint is generally not recommended during a seizure unless absolutely necessary for the safety of the client or others. Restraint can potentially cause injury to the client and increase agitation during the seizure.
C. Place the client in a prone position: Placing the client in a prone (face-down) position during a seizure is not recommended. This position may increase the risk of airway obstruction and compromise the client's ability to breathe effectively.
D. Record the time and length of the seizure: This is the correct answer. During a seizure, the nurse should prioritize ensuring the safety of the client and others. After ensuring safety, the nurse should document important details about the seizure, including the time it began and ended, as well as any observed symptoms or behaviors. This documentation can provide valuable information for the client's healthcare team and help guide future treatment decisions.
Correct Answer is C
Explanation
A. Orange-tinged urine
- This manifestation is not typically associated with nephrotic syndrome. Orange-tinged urine may indicate other conditions such as dehydration, liver disease, or the presence of certain medications or foods.
B. Hypertension
- Hypertension is not a common manifestation of nephrotic syndrome. However, it can occur in some cases due to the retention of sodium and water, which can lead to fluid overload and increased blood pressure.
C. Periorbital edema
- This is a classic manifestation of nephrotic syndrome. Periorbital edema, or swelling around the eyes, is often one of the initial signs observed in children with nephrotic syndrome due to the loss of protein in the urine, leading to fluid accumulation in the tissues.
D. Polyuria
- Polyuria, or increased urine output, is not typically associated with nephrotic syndrome. Instead, children with nephrotic syndrome may experience oliguria or normal urine output, depending on the severity of renal involvement and fluid balance.
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