A nurse is developing a plan of care for a client who has epilepsy and was admitted after experiencing a tonic-clonic seizure. Which of the following interventions should the nurse include in the plan?
Ensure padded wrist restraints are in the client's room.
Initiate IV access for the client.
Administer lorazepam every 4 hr to sedate the client.
Place an incontinence brief on the client
The Correct Answer is B
Choice A rationale:
Padded wrist restraints are not appropriate unless there's a clear clinical indication to prevent self-harm or injury.
Choice B rationale:
After a seizure, it's important to establish IV access for the client to administer medications, fluids, or other interventions if needed. Monitoring for possible postictal state, airway patency, and vital signs are also important components of care.
Choice C rationale:
Administering lorazepam every 4 hours is not a standard protocol for post-seizure management and could lead to excessive sedation.
Choice D rationale:
Placing an incontinence brief is not necessary unless there's a specific indication, and it doesn't directly relate to post-seizure care.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Taking a hot bath to relieve muscle spasms might exacerbate symptoms in individuals with multiple sclerosis due to heat sensitivity.
Choice B rationale:
Participating in high-impact exercise daily can be challenging for individuals with multiple sclerosis, who may experience fatigue and mobility issues.
Choice C rationale:
Adequate hydration is essential for individuals with multiple sclerosis to maintain overall health and support neurological function.
Choice D rationale:
Restricting daily intake of dietary fiber is not recommended, as fiber can aid in maintaining bowel regularity for individuals with multiple sclerosis.
Correct Answer is D
Explanation
Choice A rationale:
Establishing a therapeutic relationship is important, but the immediate priority is to ensure the safety of the client by maintaining constant observation.
Choice B rationale:
Instructing the client on stress management techniques is important, but safety comes first.
Choice C rationale:
Having the client sign a no-suicide contract may provide some reassurance, but it is not a substitute for constant observation.
Choice D rationale:
Maintaining constant observation of the client is the priority to prevent any further self-harm or suicide attempts.
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