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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

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A rationale:

Referring the client to crisis intervention services might be necessary, but before doing so, the nurse should gather information to understand the client's current situation and coping mechanisms.

Choice B rationale:

Assessing the client's previous coping methods helps the nurse understand the client's strengths and provides insights into potential strategies for managing the crisis effectively.

Choice C rationale:

Discussing the cause of the crisis might be helpful, but it's important to first assess the client's current coping abilities and resources.

Choice D rationale:

Assisting the client in developing strategies to overcome the crisis is important, but it should come after a thorough assessment of the client's current coping mechanisms and situation.

A. Absent deep tendon reflexes B. Fetal heart rate of 120/min C. Blood pressure 150/92 mm Hg D. Facial flushing

Correct Answer is A

Explanation

Choice A rationale:

Absent deep tendon reflexes can be a sign of magnesium toxicity, which is a potential adverse effect of magnesium sulfate infusion.

Choice B rationale:

A fetal heart rate of 120/min is within a normal range and is not concerning.

Choice C rationale:

Blood pressure of 150/92 mm Hg is elevated but is expected in a client with preeclampsia.

Choice D rationale:

Facial flushing can be a common side effect of magnesium sulfate and is not a priority finding to report.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing a crisis. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

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