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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 ["A","B","D"]

Explanation

A. Provide a suction setup at the bedside:

This is a relevant intervention as it ensures that suction equipment is readily available in case the client experiences excessive secretions or vomiting during or after a seizure. It helps maintain a clear airway and prevent aspiration.

B. Elevate the side rails when in bed:

Elevating the side rails can help ensure the client's safety during a seizure by preventing falls from the bed. It is a preventive measure to minimize the risk of injury.

C. Place a bite stick at the bedside:

Placing a bite stick at the bedside is not a recommended intervention. Bite sticks can potentially injure the patient's teeth or mouth during a seizure and are generally not recommended in current practice.

D. Keep an oxygen setup at the bedside:

This is an appropriate intervention as it ensures that oxygen is readily available in case the client experiences respiratory distress or hypoxia during or after a seizure. Oxygen therapy may be needed to support respiratory function.

E. Furnish restraints at the bedside:

Furnishing restraints at the bedside is not a recommended intervention for managing seizures. Restraints should only be used in exceptional circumstances when the client's safety or the safety of others is at risk and should be applied according to institutional policies and legal regulations.

Correct Answer is ["10"]

Explanation

To calculate the dose of valproic acid oral solution, the nurse should use the following formula:

Dose (mL) = Ordered dose (mg) / Concentration (mg/mL) x Volume (mL)

Plugging in the values from the question, we get:

Dose (mL) = 500 mg / (250 mg / 5 mL) x 5 mL

Simplifying, we get:

Dose (mL) = 500 mg / 50 mg x 5 mL

Dose (mL) = 10 mL

Therefore, the nurse should administer 10 of valproic acid oral solution to the patient.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is preparing to administer valproic acid 500 mg PO. Available is valproic acid oral solution 250 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["10"]

Explanation

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