A nurse is preparing for the admission of a client who has a seizure disorder. Which of the following supplies should the nurse place at the bedside for the client?
NG tube
Tongue blade
Suction machine
Syringe containing lorazepam
The Correct Answer is C
A) NG tube: A nasogastric (NG) tube is not typically required for a client with a seizure disorder unless they have specific feeding or aspiration concerns that require tube feeding. During a seizure, the priority is to ensure airway clearance and prevent injury, not necessarily to provide nutrition through an NG tube.
B) Tongue blade: It is a common myth that tongue blades should be used to prevent a client from biting their tongue during a seizure. However, using a tongue blade can be dangerous as it can cause injury to the mouth or teeth, or even cause choking. The nurse should never attempt to place anything in the client's mouth during a seizure.
C) Suction machine: A suction machine is essential for maintaining airway patency during or after a seizure. Clients with seizure disorders may be at risk for aspiration, and the suction machine can be used to clear secretions from the mouth to prevent choking or aspiration pneumonia. This is the most appropriate supply to place at the bedside.
D) Syringe containing lorazepam: While lorazepam (a benzodiazepine) is sometimes used for acute seizure management, it is not a routine item to have immediately at the bedside unless specifically ordered for emergency seizure intervention. The nurse should follow protocol and administer medications as prescribed, but a syringe of lorazepam is not typically pre-placed at the bedside.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"}}
Explanation
Administer phytonadione (Vitamin K): Contraindicated
There is no indication that the client has a bleeding disorder or is on anticoagulant therapy requiring Vitamin K. This intervention is not relevant to the client's condition.
Apply cool compress to the extremity: Anticipated
A cool compress helps reduce pain and swelling associated with IV infiltration by constricting blood vessels and limiting the spread of IV fluid into surrounding tissues.
Elevate extremity: Anticipated
Elevation promotes venous return and reduces edema in the infiltrated extremity, aiding in symptom relief and tissue recovery.
Suggest irrigating the IV catheter: Contraindicated
Flushing or irrigating an infiltrated IV catheter could worsen tissue damage by forcing more fluid into the surrounding area. The catheter should be removed immediately.
Assist in inserting a new IV catheter in a site distal to the infiltration site: Contraindicated
A new IV should be placed proximal (above) rather than distal to the infiltration site to ensure proper circulation and avoid further infiltration.
Send the catheter tip for culture: Anticipated
Given the client’s edema, pain, and potential IV infiltration, infection is a concern. Sending the catheter tip for culture helps rule out phlebitis or IV-related infection.
Correct Answer is B
Explanation
A) Allow the client to have 1 hour of time alone in their room:
Allowing the client to be alone in their room may not be the best option when they are pacing and wringing their hands, which may indicate anxiety or distress. Rather than isolating them, it is more appropriate to offer support and engage with the client to address the potential underlying anxiety or agitation. Time alone may escalate the feelings of distress rather than provide relief.
B) Use short, simple sentences when speaking with the client:
Using short, simple sentences is an appropriate action when interacting with a client who is pacing and wringing their hands, as this behavior can be indicative of heightened anxiety or agitation. Simple communication reduces confusion and minimizes the cognitive load on the client, helping to keep the interaction clear and calm. It can also help the nurse better assess the client’s feelings and needs in a way that feels less overwhelming to the client.
C) Ask the client if they would like to watch television:
While offering the option of watching television could be an attempt to distract or comfort the client, it does not directly address the potential underlying anxiety or distress the client may be experiencing. It is important to first assess and manage the client’s emotional state before offering distractions like television, which may not effectively address the root of the issue.
D) Move the client to a table where other clients are playing cards:
Moving the client to a group activity may not be the best approach in this situation. The client is demonstrating signs of anxiety or agitation, and suddenly introducing them to a group environment might be overwhelming and could increase their distress. It is more appropriate to first engage the client in a calm, one-on-one interaction using simple communication, and then consider group activities if the client appears ready for them.
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