A nurse on a medical unit is caring for a client who requires seizure precautions. Which of the following interventions should the nurse contribute to the client's plan of care?

Keep the lights on when the client is sleeping.

Restrain the client as soon as seizure activity begins.

Have a padded tongue depressor available at the bedside.

Keep the client's bed in the lowest position.

Answer and Explanation

The Correct Answer is D

A. Keeping the lights on when the client is sleeping is not a standard intervention for seizure precautions. In fact, it's generally recommended to create a quiet and low-stimulus environment for clients with seizure disorders.

B. Restraining the client as soon as seizure activity begins is not recommended. Restraints can lead to injuries and complications during a seizure. It is essential to allow the client to move and prevent injury by removing harmful objects from the vicinity.

C. Having a padded tongue depressor available at the bedside is not a standard intervention for seizure precautions. In the event of a seizure, the priority is to keep the client safe, protect their head, and ensure a clear airway. Placing objects in the mouth is not recommended and can lead to injury.

D. Keeping the client's bed in the lowest position is a safety measure to prevent injuries during a seizure. It reduces the risk of falling from a significant height in case of a seizure episode.

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Correct Answer is A

Explanation

A. Keep the client's personal items within reach.Keeping the client's personal items within reach can provide a sense of familiarity and comfort, which may reduce anxiety or disorientation, thereby decreasing the tendency to wander.

Incorrect options:

B. "Tell the family that someone should plan to stay with the client.": While family involvement is important, this suggestion may not always be feasible. Additionally, it’s the nurse’s role to ensure the safety of the client within the facility.

C. "Place the client in a quiet room at the end of the hallway.": Isolating the client may increase confusion and feelings of disorientation.

D. "Provide bright lighting in the client's room at night.": Bright lights at night can disrupt sleep and may cause further disorientation. Dim or soft lighting or use of night lights in the room is generally more appropriate to promote restful sleep.

A. Concurrent treatment for GERD B. History of breast cancer C. History of dermatitis D. Multiple hospitalizations for COPD

Correct Answer is B

Explanation

A. Concurrent treatment for GERD (gastroesophageal reflux disease) is not typically a contraindication for hormone replacement therapy. However, it's essential to assess the specific details of the client's medical history and medications to ensure safe use.

B. A history of breast cancer is a significant contraindication for hormone replacement therapy. Estrogen, a component of many HRT regimens, can stimulate the growth of certain types of breast cancer. Therefore, HRT is generally avoided in individuals with a history of breast cancer.

C. A history of dermatitis is not typically a contraindication for hormone replacement therapy. However, individual circumstances should be considered, and any concerns related to skin conditions should be discussed with the healthcare provider.

D. Multiple hospitalizations for COPD (chronic obstructive pulmonary disease) may not be a direct contraindication for hormone replacement therapy, but the overall health status and individual medical history should be carefully considered before initiating HRT.

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A nurse on a medical unit is caring for a client who requires seizure precautions. Which of the following interventions should the nurse contribute to the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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