A client has a prescription for seizure precaution. Which intervention should the nurse include in the plan of care?

Keep the bed in the highest position

Keep seizure medication at the bedside at all times

Keep very bright lights in the client's room during the night

Keep the bed locked in the lowest position .

Answer and Explanation

The Correct Answer is B

Choice A is incorrect. While keeping the bed in a high position can minimize fall risk, it is not a specific precaution for preventing seizures. In fact, some types of seizures can be triggered by sudden changes in position.

Choice C is incorrect. Bright lights can worsen seizure activity and should be avoided, especially during the night when the client is more likely to be photosensitive.

Choice D is incorrect. Locking the bed in the lowest position can increase fall risk and is not a specific precaution for preventing seizures.

Rationale for Choice B:
Having seizure medication readily available at the bedside allows for immediate administration in case of a seizure, which can minimize its duration and severity. This is a crucial intervention for seizure precaution.
Keeping the medication within easy reach also ensures prompt administration by healthcare personnel or caregivers, further improving the client's safety and outcome.

Additionally, easy access to the medication empowers the client or caregiver to participate actively in their own care and respond quickly to a potential seizure.
Therefore, based on the importance of immediate access to seizure medication in managing and preventing seizures, Choice B is the most appropriate intervention to include in the client's plan of care.

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Correct Answer is A

Explanation

Choice A rationale:
Coughing and deep breathing: These techniques directly promote airway clearance by mobilizing and expelling secretions from the lungs. They are essential for clients with pneumonia, as the buildup of secretions can obstruct the airways and impair gas exchange.
Hydration maintenance: Adequate hydration helps to thin secretions, making them easier to cough up and clear from the lungs. It also helps to prevent dehydration, which can worsen respiratory symptoms.

Choice B rationale:
Keeping the head of the bed elevated: This can help to improve breathing by decreasing the work of breathing and promoting lung expansion. However, it is not the most effective intervention for directly clearing secretions from the lungs.

Choice C rationale:
Preparation for insertion of a tracheostomy tube: This is a more invasive intervention that may be necessary in severe cases of airway obstruction. However, it is not the priority intervention for a client with ineffective airway clearance related to pneumonia.

Choice D rationale:
Providing supplemental oxygen: This can help to improve oxygenation in clients with pneumonia. However, it does not directly address the problem of ineffective airway clearance.

A. Restrict weight-bearing on the right foot B. Ensure fluid intake of at least 8 liters per day C. Restrict consumption of foods high in purines D. Take OTC calcium supplements consistently

Correct Answer is C

Explanation

Choice A rationale:
Restricting weight-bearing on the affected foot may provide some temporary relief from pain during an acute gout attack. However, it is not a long-term management strategy and can lead to muscle weakness and joint stiffness. It's important to gradually resume weight-bearing activities as tolerated to maintain joint function.

Choice B rationale:
Adequate fluid intake is essential for overall health and can help to flush out uric acid from the body. However, 8 liters per day is an excessive amount of fluid and could lead to electrolyte imbalances and other health problems. A more appropriate recommendation for a client with gout would be to aim for a fluid intake of 2-3 liters per day, unless otherwise advised by a healthcare provider.

Choice C rationale:
Restricting consumption of foods high in purines is a key management strategy for gout. Purines are substances found in certain foods that break down into uric acid in the body. High levels of uric acid can lead to the formation of urate crystals, which deposit in joints and cause inflammation and pain. Examples of foods high in purines include organ meats, red meat, seafood, and some types of beans and lentils.

Choice D rationale:
Calcium supplements have not been shown to be effective in the management of gout. In fact, some studies have suggested that calcium supplements may even increase the risk of gout attacks.

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A client has a prescription for seizure precaution. Which intervention should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What intervention should the nurse identify as a priority for a client with a nursing diagnosis of ineffective airway clearance related to HIV-related pneumonia?

Correct Answer is A

Explanation

A client comes to the clinic with a complaint of pain in the right great toe and is eventually diagnosed with gout. When planning teaching for this client, what management technique should the nurse emphasize?

Correct Answer is C

Explanation

A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

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