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 ["C","D","E","G"]

Explanation

A) The client’s blood glucose in this scenario is within the normal range.
B) The bowel sounds in this scenario are present in all the 4 quadrants which is normal.
C) The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
D) The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
E) The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
F) The lungs are clear on auscultation of all the lobes which is normal.

G) The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.

A. Pain level B. Respiratory rate C. Heart rate D. Oxygenation saturation E. Blood pressure F. Echocardiogram results G. Urinary output

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

Explanation

A) The client's pain level decreased from 7 to 5 after receiving nitroglycerin. This decrease indicates improvement in the client's condition.
B) The client’s respiratory rate decreased from 24/min to 22/min.
C) The client’s heart rate decreased from 120/min to 100/min.

D) Initially, the client's oxygen saturation was 93% on room air, which decreased to 89%. However, after receiving oxygen at 2 L/min via nasal cannula it improved to 92%.
E) The blood pressure decreased from 176/82 to 110/62.

F) Only one echocardiogram result showing myocardial infarction was provided.

G) Only one reading of I&O was provided showing an output of 32 mL, hence difficult to determine whether there was an improvement.

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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?

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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?