A nurse is planning care for a client who has a history of seizures. Which of the following interventions should the nurse include in the plan of care?

Plan to insert an oral airway if seizure activity begins.

Plan to administer pain medication after the seizure.

Pad the side rails of the client's bed with blankets.

Place the client in a supine position during a seizure.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Planning to insert an oral airway if seizure activity begins is not a suitable intervention for a client with a history of seizures. During a seizure, it's essential to protect the client from injury by preventing them from aspirating secretions or foreign objects. However, inserting an oral airway during an active seizure can be dangerous and lead to injury.

Choice B rationale:

Administering pain medication after the seizure is not a priority intervention. While some clients may experience muscle soreness or discomfort following a seizure, the primary focus during and immediately after a seizure is ensuring the client's safety and preventing injury. Pain medication can be considered later if necessary.

Choice C rationale:

The correct choice is to pad the side rails of the client's bed with blankets. This intervention aims to prevent injury if the client experiences a seizure and comes into contact with the bed rails. Padding the side rails can reduce the risk of trauma and minimize the potential for harm during a seizure episode.

Choice D rationale:

Placing the client in a supine position during a seizure is not recommended. It's important to position the client on their side (lateral recumbent position) during a seizure to allow any oral secretions or vomit to drain from the mouth, reducing the risk of aspiration. Placing the client supine could obstruct the airway and increase the risk of aspiration.

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Correct Answer is C

Explanation

Choice A rationale:

The neighbor is not authorized to provide consent for the client's procedure. The durable power of attorney for health care typically designates someone to make medical decisions when the client is unable to do so, but the neighbor's role may not extend to medical procedure consent.

Choice B rationale:

The client's spouse might have a legal standing to make decisions for the client, but the durable power of attorney for health care typically takes precedence over the spouse's decision-making authority in situations where it has been established.

Choice C rationale:

The provider, in this case, the medical doctor or healthcare professional performing the endoscopy, has the authority to obtain consent for the procedure. Informed consent is a crucial ethical and legal requirement, and the provider must ensure that the client or their designated decision-maker understands the procedure, its risks, and benefits before proceeding.

Choice D rationale:

A member of the facility's ethics committee does not typically have the authority to provide consent for a specific medical procedure on behalf of an incapacitated client. The ethics committee's role is to provide guidance on ethical dilemmas and issues but not to provide individual procedural consent.

A. Large pieces of furniture. B. A bedside table next to the bed. C. Raised toilet seats. D. Throw rugs on hardwood floors.

Correct Answer is D

Explanation

Choice A rationale:

Large pieces of furniture do not necessarily create a significant risk for falls unless they are poorly placed or obstructing pathways. While they can potentially cause accidents, the likelihood of tripping over them is generally lower compared to other hazards.

Choice B rationale:

A bedside table next to the bed is not a significant fall risk factor. In fact, having a bedside table can be beneficial for the client, as it provides a convenient surface for placing items that the client might need during the night.

Choice C rationale:

Raised toilet seats, although they may pose a challenge for individuals with mobility issues, are typically installed to aid those with difficulty sitting down or standing up. They are not a primary risk factor for falls, especially when compared to other more hazardous factors.

Choice D rationale:

Throw rugs on hardwood floors are a significant fall risk factor, especially for older adults or individuals with mobility problems. The rugs can easily shift or bunch up, causing someone to trip and fall. Hardwood floors can also become slippery, and the combination of a throw rug on such a surface increases the risk of accidents. The rationale behind this choice is grounded in the potential for tripping and slipping hazards that these throw rugs can introduce, especially in individuals who might already have balance or mobility issues.

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A nurse is planning care for a client who has a history of seizures. Which of the following interventions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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