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A nurse is reinforcing discharge teaching to a client who has epilepsy. Which of the following instructions should be included in the teaching?

Placing padding around or under the patient's head

Positioning the patient on the side once the relaxation stage is entered to allow oral secretions to drain

Have the necessary equipment and/or personnel in case the patient doesn't spontaneously breath when the seizure is over

Insert a tongue depressor in the patient's mouth

Note the time the seizure started

Hold the patient down to prevent injury

Answer and Explanation

Correct Answer : A,B,C,E

A. Placing padding around or under the patient's head

This is a helpful instruction to include. Placing padding around or under the patient's head can help prevent injury during a seizure by cushioning the head against impact with the ground.

B. Positioning the patient on the side once the relaxation stage is entered to allow oral secretions to drain

This is a correct instruction. Positioning the patient on their side (recovery position) can help prevent aspiration if vomiting occurs during or after the seizure. It also helps clear oral secretions and maintain a clear airway.

C. Having the necessary equipment and/or personnel in case the patient doesn't spontaneously breathe when the seizure is over

This is an important instruction. It is crucial to have emergency equipment (such as oxygen and suction) readily available and to be prepared to provide respiratory support if the patient does not spontaneously breathe after the seizure.

D. Inserting a tongue depressor in the patient's mouth

This is an incorrect instruction. It is not recommended to insert anything into the patient's mouth during a seizure as it can cause injury to the teeth, gums, or airway. Additionally, it is a common misconception that tongue swallowing occurs during seizures, which is rare.

E. Noting the time the seizure started

This is a critical instruction. Noting the time the seizure started helps healthcare providers assess the duration of the seizure and determine if medical intervention is necessary. It also helps monitor the patient's recovery and response to treatment.

F. Holding the patient down to prevent injury

This is an incorrect instruction. Holding the patient down during a seizure can cause injury to both the patient and the person restraining them. It is important to create a safe environment by removing hazards and guiding the patient away from dangerous objects or situations, but holding them down is not appropriate.

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Correct Answer is B

Explanation

A. Insert a padded tongue blade into the client's mouth.

This intervention is not recommended. Placing any object, including a padded tongue blade, into the mouth of someone experiencing a seizure poses a risk of injury, such as biting the tongue or breaking teeth. It can also obstruct the airway and increase the risk of aspiration. Therefore, inserting anything into the client's mouth during a seizure is contraindicated.

B. Place a pillow under the client's head.

Placing a pillow under the client's head can help prevent head injury by providing cushioning and support. It can also help maintain the client's airway and reduce the risk of aspiration. Therefore, this intervention is appropriate and helps ensure the client's safety during the seizure.

C. Gently restrain the client's extremities.

Restraining the client's extremities is not recommended during a seizure. It can increase the risk of injury, such as fractures or dislocations, and may exacerbate muscle contractions. It's important to allow the client's movements to occur naturally while taking measures to ensure their safety, such as removing nearby objects and providing a safe environment.

D. Keep the client in a supine position.

It is essential to ensure that the client's head is turned to the side (recovery position) to prevent aspiration and allow for drainage of oral secretions. Additionally, the nurse should remove any nearby objects that could pose a risk of injury during the seizure.

A. Perform passive range of motion on each extremity. B. Monitor the client's electrolyte levels. C. Suction saliva from the client's mouth. D. Record the client's intake and output.

Correct Answer is C

Explanation

A. Perform passive range of motion on each extremity:

While passive range of motion exercises are important for preventing contractures and maintaining joint mobility in immobilized clients, they are not the highest priority in this situation. Airway management takes precedence over mobility exercises.

B. Monitor the client's electrolyte levels:

Monitoring electrolyte levels is important for overall assessment and management of the client's health, but it is not the highest priority when the client's airway and breathing are compromised.

C. Suction saliva from the client's mouth:

This is the correct answer. Suctioning saliva from the client's mouth helps maintain a clear airway and prevents aspiration. Unconscious clients are at risk for pooling of oral secretions, which can obstruct the airway and lead to respiratory complications.

D. Record the client's intake and output:

While monitoring intake and output is an essential part of nursing care, it is not the highest priority when the client's airway and breathing are compromised.

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A nurse is reinforcing discharge teaching to a client who has epilepsy. Which of the following instructions should be included in the teaching?

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