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 B
Explanation
A. "The doctor can best help you with that after your physical examination."
This response implies that a physical examination is necessary before discussing contraception, which may not be accurate. Contraceptive counseling can often occur without a physical examination, and the nurse can provide initial guidance based on the information available.
B. "Before I can help you with that question, I need to know more about your sexual activity."
This response is appropriate because it acknowledges the need for more information to provide personalized advice. It respects the individual's privacy while recognizing that different contraceptive methods may be suitable based on factors like sexual activity, health history, and personal preferences.
C. "You are so young. Are you sure you are ready for the responsibilities of a sexual relationship?"
This response may come across as judgmental and could potentially discourage open communication. It's essential to maintain a non-judgmental and supportive attitude when discussing sexual health with adolescents. Instead of questioning their readiness, the focus should be on providing accurate information and support.
D. "Because of your age, we need your parents' consent for an examination, and then we'll talk."
This response may not be appropriate as it suggests a potential barrier to seeking advice about contraception. Many jurisdictions allow adolescents to receive confidential reproductive health services, including contraception, without parental consent. Encouraging open communication and respecting confidentiality is crucial in supporting adolescents' access to reproductive healthcare.
Correct Answer is A
Explanation
A. "I need to talk to you about unit expectations regarding timely completion of tasks."
This statement is non-confrontational and focuses on discussing the expectations of the unit regarding task completion. It allows the nurse to address the specific behavior (taking long breaks and making personal phone calls) without making accusatory or negative statements.
B. "You have been very inconsiderate of others by not completing your share of the work."
This statement may be perceived as accusatory and could escalate the conflict. It is important to communicate concerns without placing blame.
C. "Several staff members have commented that you don't do your fair share of the work."
This statement involves bringing in third-party opinions, which may not be the most direct and effective way to address the issue. It's better to address the concern directly with the individual involved.
D. "If you don't do your share of the work, I will have to inform the nurse manager."
Threatening to inform the nurse manager without first addressing the issue through communication can escalate the conflict. It's generally more productive to attempt to resolve conflicts through open and direct communication before involving higher authorities.
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