A nurse is contributing to the plan of care for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan? (Select all that apply.)
Provide a suction setup at the bedside.
Elevate the side rails when in bed.
Place a bite stick at the bedside.
Keep an oxygen setup at the bedside.
Furnish restraints at the bedside.
Correct Answer : A,B,D
A. Provide a suction setup at the bedside:
This is a relevant intervention as it ensures that suction equipment is readily available in case the client experiences excessive secretions or vomiting during or after a seizure. It helps maintain a clear airway and prevent aspiration.
B. Elevate the side rails when in bed:
Elevating the side rails can help ensure the client's safety during a seizure by preventing falls from the bed. It is a preventive measure to minimize the risk of injury.
C. Place a bite stick at the bedside:
Placing a bite stick at the bedside is not a recommended intervention. Bite sticks can potentially injure the patient's teeth or mouth during a seizure and are generally not recommended in current practice.
D. Keep an oxygen setup at the bedside:
This is an appropriate intervention as it ensures that oxygen is readily available in case the client experiences respiratory distress or hypoxia during or after a seizure. Oxygen therapy may be needed to support respiratory function.
E. Furnish restraints at the bedside:
Furnishing restraints at the bedside is not a recommended intervention for managing seizures. Restraints should only be used in exceptional circumstances when the client's safety or the safety of others is at risk and should be applied according to institutional policies and legal regulations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "It is too early to tell. When the spinal shock subsides, we will know more."
This response is appropriate. Spinal shock can initially obscure the extent of neurological injury, and it may take time for the full extent of the injury to become apparent. By acknowledging this and suggesting that more information will be available once spinal shock subsides, the nurse provides a realistic perspective without prematurely predicting the outcome.
B. "You should talk to your physician about things of that nature."
This response may come across as dismissive or evasive. While it is true that the physician ultimately determines the patient's prognosis, the family may be seeking reassurance and guidance from the nurse as well.
C. "No. Significant recovery of function should occur in a few days."
This response is overly optimistic and potentially misleading. While some improvement may occur in the days following a spinal cord injury, significant recovery of function within a few days is unlikely, especially in cases of flaccid paralysis of all extremities.
D. "Yes. In all likelihood, the paralysis is probably permanent."
This response is overly pessimistic and lacks sensitivity. It may unnecessarily distress the family and extinguish hope for the patient's recovery.
Correct Answer is B
Explanation
A. Excessive salivation:
Excessive salivation is not a common adverse effect of benztropine. Instead, anticholinergic medications like benztropine often cause dry mouth, which is more common than excessive salivation.
B. Difficulty voiding:
Difficulty voiding, or urinary retention, is a potential adverse effect of anticholinergic medications like benztropine. Anticholinergic drugs can cause relaxation of the detrusor muscle in the bladder, leading to urinary retention. Therefore, the nurse should instruct the client to report any difficulty or inability to urinate.
C. Diarrhea:
Diarrhea is not a common adverse effect of benztropine. Instead, anticholinergic medications like benztropine typically cause constipation due to their antimuscarinic effects on the gastrointestinal tract.
D. Slow pulse:
Slow pulse, or bradycardia, is not a common adverse effect of benztropine. Instead, anticholinergic medications like benztropine may cause tachycardia (increased heart rate) due to their effects on the autonomic nervous system.
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