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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 D

Explanation

Choice A rationale:

Other family members or close contacts may consider immunization, but it is not directly related to the client's ALS diagnosis.

Choice B rationale:

Since the client has a new diagnosis of ALS, the immediate focus should not be on selling their home, but rather on understanding and managing the disease.

Choice C rationale:

Requiring hospice care immediately is not a standard recommendation for a client with ALS. The client's disease progression and needs will be assessed to determine the appropriate level of care.

Choice D rationale:

Creating a living will is important for clients with a terminal illness like ALS, as it allows them to express their wishes for medical treatment and care preferences in advance.

A. "You will need to have your blood drawn every 2 weeks." B. "You will self-administer one dose intramuscularly each day." C. "This medication is safe to take if you become pregnant. D. "You should limit your daily fluid intake to 1 and a half liters."

Correct Answer is A

No explanation

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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?

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