A nurse is planning care for a client who is experiencing seizures secondary to meningitis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Place a tongue blade at the bedside.

Dim the overhead lights.

Assist the client to ambulate every 4 hr.

Apply a warming blanket.

Have suction equipment at the bedside.

Answer and Explanation

Correct Answer : B,E

A. Place a tongue blade at the bedside: Keeping a tongue blade at the bedside is not recommended because attempting to insert an object into the mouth during a seizure can cause injury to the teeth, gums, or airway. Instead, the focus should be on maintaining a safe environment and protecting the client from harm.

B. Dim the overhead lights: Meningitis can cause photophobia, or sensitivity to light, which can worsen discomfort and potentially trigger seizures. Dimming the lights helps reduce sensory stimulation and promotes comfort, decreasing the risk of further neurological agitation.

C. Assist the client to ambulate every 4 hr: Clients experiencing seizures should have activity restrictions to prevent falls and injuries. Ambulation should be supervised and only encouraged once the client is stable. Frequent rest is preferred to minimize exhaustion, which can contribute to seizure activity.

D. Apply a warming blanket: Meningitis can cause fever, but applying a warming blanket is not appropriate unless the client is experiencing hypothermia. Fever management typically involves antipyretics and cooling measures, such as tepid sponge baths or light clothing, rather than warming interventions.

E. Have suction equipment at the bedside: During a seizure, excessive secretions or impaired airway protection can lead to aspiration. Having suction equipment readily available allows for quick clearance of the airway once the seizure subsides, reducing the risk of respiratory complications.

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Correct Answer is A

Explanation

A. Desmopressin acetate: This synthetic form of antidiuretic hormone (ADH) reduces excessive urine output by increasing water reabsorption in the kidneys. It helps restore fluid balance and prevent dehydration in diabetes insipidus. Without treatment, continued polyuria can lead to severe dehydration and electrolyte imbalances.

B. Spironolactone: This potassium-sparing diuretic promotes sodium and water excretion by blocking aldosterone receptors. It is used to treat conditions like heart failure and hyperaldosteronism but would worsen polyuria and dehydration in diabetes insipidus.

C. Furosemide: This loop diuretic inhibits sodium and chloride reabsorption in the kidneys, leading to increased urine output. Administering it to a client with diabetes insipidus would further aggravate excessive fluid loss and the risk of dehydration.

D. Dopamine: This vasopressor is used to improve cardiac output and blood pressure in conditions like shock. It does not affect ADH levels or urine concentration and would not help manage the excessive diuresis seen in diabetes insipidus.

A. "I should use a heating pad when my feet are cold." B. "I should plan to remain barefoot while I am at home." C. "I should apply lotion between my toes twice a day." D. "I should file the edges of my toenails after trimming them."

Correct Answer is D

Explanation

A. "I should use a heating pad when my feet are cold.": Clients with diabetes mellitus may have reduced sensation due to peripheral neuropathy. Using a heating pad increases the risk of burns or injury due to the inability to perceive excessive heat.

B. "I should plan to remain barefoot while I am at home.": Walking barefoot increases the risk of foot injuries, which can lead to infections and complications such as diabetic ulcers. Clients should always wear well-fitting shoes, even at home, to protect their feet.

C. "I should apply lotion between my toes twice a day.": Moisturizing the feet is important to prevent dryness and cracking, but applying lotion between the toes can create excess moisture, increasing the risk of fungal infections.

D. "I should file the edges of my toenails after trimming them.": Filing the edges helps smooth sharp corners, reducing the risk of ingrown toenails and foot injuries, which can be difficult to heal in individuals with diabetes.

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A nurse is planning care for a client who is experiencing seizures secondary to meningitis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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