A nurse on the medical-surgical unit is caring for a client who has a seizure disorder.

Which of the following interventions should the nurse include in the plan of care?

Pad the upper two side rails of the client's bed.

Maintain peripheral IV access.

Teach assistive personnel how to apply restraints.

Keep a padded tongue blade at the client's bedside.

Answer and Explanation

The Correct Answer is A

A)   Padding the upper two side rails of the client's bed helps prevent injury during a seizure by reducing the risk of head trauma.
B)   Maintaining peripheral IV access may not directly address the client's safety during a seizure.
C)   Teaching assistive personnel to apply restraints is not appropriate for managing seizures and may not be indicated unless other safety measures have failed.
D)   Keeping a padded tongue blade at the client's bedside is not necessary and may not be safe if the client experiences a seizure.

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Correct Answer is ["69"]

Explanation

To calculate the daily protein requirement for the client, first convert the weight from pounds to kilograms, knowing that 1 kilogram equals 2.2 pounds.

The client's weight in kilograms is 190 lb divided by 2.2, which equals approximately

86.36 kg.

Then, multiply the weight in kilograms by the recommended dietary allowance (RDA) of protein, which is 0.8 g/kg. So, 86.36 kg multiplied by 0.8 g/kg equals about

69.09 g. Rounding to the nearest whole number, the client should receive 69 grams of protein daily.

A. A client who has peritonitis reports generalized abdominal pain. B. A client who has pancreatitis reports pain in the left shoulder. C. A client who has angina reports substernal chest pain. D. A client who is postoperative reports incisional pain.

Correct Answer is B

Explanation

A) Generalized abdominal pain reported by a client with peritonitis indicates visceral pain.
B) Pain in the left shoulder reported by a client with pancreatitis is an example of referred pain, as it occurs at a site distant from the actual pathology.
C) Substernal chest pain reported by a client with angina indicates cardiac pain, not referred pain.
D) Incisional pain reported by a postoperative client is localized and does not indicate referred pain.

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A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["69"]

Explanation

A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?

Correct Answer is B

Explanation

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A nurse on the medical-surgical unit is caring for a client who has a seizure disorder.

Which of the following interventions should the nurse include in the plan of care?