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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Newborns typically lose some weight after birth, but 15 percent loss would be excessive and concerning. A normal weight loss range is about 5 to 10 percent.
Choice B rationale:
Newborns should be fed on demand rather than adhering to strict schedules to ensure they are adequately nourished.
Choice C rationale:
Breastfeeding requires additional energy, and mothers are generally advised to consume around 500 extra calories a day to support milk production and their own energy needs.
Choice D rationale:
Offering a pacifier before sleep can reduce the risk of sudden infant death syndrome (SIDS), but this recommendation usually starts at around 1 to 2 months of age.
Correct Answer is B
Explanation
A. Taking estrogen supplements does not significantly increase infection risk in clients receiving chemotherapy.
B. A 70-year-old client with chronic obstructive pulmonary disease (COPD) is at greatest risk for infection because advanced age and chronic lung disease both impair immune function and increase susceptibility to respiratory infections, especially during chemotherapy.
C. A left arm fracture may increase local infection risk, but it does not pose as high a systemic infection risk as COPD in an older adult.
D. Having a thin build does not inherently increase infection risk in the context of chemotherapy.
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