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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 C

Explanation

A. Semicomatose:

This term suggests a state between consciousness and coma. A patient who is semicomatose may exhibit some level of responsiveness but is typically unresponsive or only responds to intense stimuli.

B. Somnolent:

Somnolence refers to a state of drowsiness or sleepiness. A somnolent patient may appear sleepy, have difficulty staying awake, and may be slow to respond to stimuli. However, the withdrawal from painful stimuli described in the scenario suggests a higher level of responsiveness than what would typically be expected in a somnolent state.

C. Lethargic:

Lethargy describes a state of reduced alertness or responsiveness. A lethargic patient may appear drowsy, sluggish, and have diminished responses to stimuli. The description of the patient as stuporous (having a decreased level of consciousness) but still reacting by withdrawing from painful stimuli aligns with the characteristics of lethargy.

D. Comatose:

Coma refers to a state of profound unconsciousness where the patient is unresponsive to all stimuli, including painful stimuli. A comatose patient does not demonstrate any purposeful movement or response to stimuli. Since the patient in the scenario exhibits some response to painful stimuli by withdrawing, they do not meet the criteria for being comatose.

A. Monitor for elevated blood pressure. B. Provide analgesia for headaches. C. Prevent bladder distention. D. Elevate the client's head.

Correct Answer is C

Explanation

A.While monitoring for elevated blood pressure is important in identifying autonomic dysreflexia once it occurs, it does not prevent the condition. The nurse should focus on eliminating potential triggers, such as bladder distention or constipation, to prevent the occurrence.

B.Headaches are a symptom of autonomic dysreflexia, often related to severe hypertension. While treating the headache may alleviate discomfort, it does not address the underlying cause, nor does it prevent the onset of autonomic dysreflexia.

C.Bladder distention is a common trigger for autonomic dysreflexia in individuals with spinal cord injuries. The nurse should ensure that the client's bladder is regularly emptied to prevent overdistention, which can stimulate the autonomic reflex and trigger AD.

D.Elevating the head is an intervention used during an episode of autonomic dysreflexia to help lower blood pressure and reduce symptoms. However, this action does not prevent the condition from occurring.

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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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