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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
A. Water heater temperature 54.4°C (130° F):
This water heater temperature is too high and poses a scalding risk. The recommended temperature setting for water heaters is generally below 49°C (120° F) to prevent burns.
B. Electric cords behind furniture:
Placing electric cords behind furniture can create tripping hazards. It is safer to have cords organized and placed away from areas where the client may walk.
C. Bathtub with rails:
Having a bathtub with rails is a safety feature that can assist the client in getting in and out of the bathtub safely. It is not a safety risk.
D. Raised toilet seats:
Raised toilet seats are often recommended for older adults to facilitate safe and easier use of the toilet. They are not a safety risk when used appropriately.
E. Throw rugs:
Throw rugs can be a tripping hazard, especially for older adults who may have mobility issues. They should be secured or removed to prevent falls.
Correct Answer is ["0.5"]
Explanation
To administer lorazepam 1 mg PO to an older adult client who has insomnia and who cannot swallow oral tablets, the nurse should use the lorazepam oral solution 2 mg/mL.
The nurse should calculate the dose by using the formula: Dose (mL) = Desired dose (mg) / Available dose (mg/mL).
In this case, the desired dose is 1 mg and the available dose is 2 mg/mL.
Therefore, the dose (mL) = 1 mg / 2 mg/mL = 0.5 mL.
The nurse should plan to administer 0.5 mL of lorazepam oral solution to the client.
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