A client has been admitted with new-onset status epilepticus. Which seizure precautions would the nurse implement? (Select all that apply.)
Suction equipment at the bedside.
Continuous sedation.
Side rails padded.
Bed in low position.
Intravenous (IV) access.
Correct Answer : A
Choice A Reason:
Suction equipment at the bedside.
Having suction equipment at the bedside is crucial for a client with status epilepticus. During a seizure, there is a risk of aspiration due to excessive salivation or vomiting. Suction equipment allows the nurse to quickly clear the airway, preventing aspiration and ensuring the client can breathe properly. This precaution is essential to maintain the client’s airway and prevent complications such as aspiration pneumonia.
Choice B Reason:
Continuous sedation.
Continuous sedation is not typically a standard precaution for all clients with status epilepticus. While sedation may be necessary in some cases to control seizures, it is not a universal precaution. The primary goal is to stop the seizure activity and stabilize the client. Continuous sedation may be used in specific situations under close medical supervision, but it is not a general precaution that nurses implement for all clients with status epilepticus.
Choice C Reason:
Side rails padded.
Padding the side rails of the bed is an important precaution to prevent injury during a seizure. Clients experiencing seizures may have uncontrolled movements, which can lead to injury if they hit the hard surfaces of the bed. Padded side rails help to cushion these impacts, reducing the risk of bruises, cuts, or fractures. This precaution is essential for ensuring the client’s safety during seizure activity.
Choice D Reason:
Bed in low position.
Keeping the bed in a low position is another important safety measure. If a client with status epilepticus were to fall out of bed during a seizure, the lower height reduces the risk of serious injury. This precaution helps to minimize the impact of any potential falls, ensuring the client’s safety. It is a simple yet effective measure to prevent harm during seizure episodes.
Choice E Reason:
Intravenous (IV) access.
Establishing intravenous (IV) access is critical for a client with status epilepticus. IV access allows for the rapid administration of medications needed to control seizures and manage the client’s condition. In an emergency, quick access to the bloodstream is essential for delivering life-saving treatments. This precaution ensures that the medical team can promptly and effectively intervene to stop the seizure activity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Baclofen is primarily used to treat muscle symptoms caused by multiple sclerosis, including muscle spasms, stiffness, and pain1. It acts on the spinal cord nerves to decrease the number and severity of muscle spasms, thereby improving muscle movement2. The effectiveness of baclofen in managing multiple sclerosis symptoms is best evaluated by assessing the reduction in muscle spasms.
Choice B reason:
While mood and affect are important aspects of a patient’s overall well-being, they are not the primary indicators of baclofen’s effectiveness. Baclofen does not have a direct impact on mood and affect, as its main function is to relieve muscle spasms and improve muscle movement.
Choice C reason:
Appetite is not a primary concern when evaluating the effectiveness of baclofen. This medication is not known to significantly affect appetite. The main therapeutic goal of baclofen is to reduce muscle spasms and improve mobility in patients with multiple sclerosis.
Choice D reason:
Sleep pattern, although important for overall health, is not the primary measure of baclofen’s effectiveness. Baclofen’s primary role is to alleviate muscle spasms and improve muscle function. While it may have some impact on sleep due to its muscle-relaxing properties, this is not the main criterion for evaluating its effectiveness.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason: A buffalo hump is a characteristic sign of Cushing’s syndrome. It refers to the accumulation of fat on the back of the neck and shoulders. This symptom occurs due to the excessive production of cortisol, which leads to abnormal fat distribution in the body.
Choice B reason: Moon face is another hallmark of Cushing’s syndrome. It describes the rounding and fullness of the face, which results from fat deposits. This symptom is also caused by prolonged exposure to high levels of cortisol.
Choice C reason: Hypertension, or high blood pressure, is commonly associated with Cushing’s syndrome. Cortisol increases blood pressure by enhancing the sensitivity of blood vessels to catecholamines and by promoting sodium and water retention.
Choice D reason: Purple striations, or stretch marks, are often seen in individuals with Cushing’s syndrome. These marks typically appear on the abdomen, thighs, breasts, and arms. They result from the thinning of the skin and the breakdown of collagen due to elevated cortisol levels.
Choice E reason: Tremors are not typically associated with Cushing’s syndrome. While Cushing’s syndrome can cause a variety of symptoms, tremors are more commonly linked to other conditions such as hyperthyroidism or neurological disorders.
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