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A nurse working on a medical unit is caring for a patient who is placed on seizure precautions. Which of the following interventions should the nurse include in the patient's plan of care?

Keep a padded tongue blade available at the patient's bedside.

Place the patient's bed in the high position.

Keep the lights on when the patient is sleeping.

Obtain IV access.

Answer and Explanation

The Correct Answer is D

A. Incorrect. Never insert anything into a seizing patient's mouth, as it can cause injury.

B. Incorrect. The bed should be in the lowest position to prevent falls.

C. Incorrect. Keeping lights on is unnecessary and can cause sensory overstimulation.

D. Correct. IV access is important in case emergency medications (e.g., lorazepam) are needed during a seizure.

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Correct Answer is C

Explanation

A. The patient states having nasal congestion. – Incorrect. Nasal congestion is a symptom of autonomic dysreflexia, not a trigger.

B. The patient’s blood pressure becomes elevated. – Incorrect. Hypertension is a symptom of autonomic dysreflexia, not the cause.

C. The patient’s bladder becomes distended. – Correct Answer. Bladder distention is the most common trigger of autonomic dysreflexia, a life-threatening condition causing sudden hypertension, bradycardia, and severe headache. Immediate intervention is needed, such as catheterizing the bladder.

D. The patient states having a severe headache. – Incorrect. A severe headache is a symptom of autonomic dysreflexia, not a cause.

A. A child who has a sprained wrist B. A child who has pneumonia C. A child who has rheumatic fever D. A child recovering from a ruptured appendix

Correct Answer is A

Explanation

A. A child with a sprained wrist is non-infectious and poses no risk to the immunocompromised leukemia patient.

B. Pneumonia is a contagious respiratory infection that poses a high risk.

C. Rheumatic fever can involve post-streptococcal infection risks.

D. A ruptured appendix increases the risk of infection due to peritonitis.

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A nurse working on a medical unit is caring for a patient who is placed on seizure precautions. Which of the following interventions should the nurse include in the patient's plan of care?

Nursing Test Bank

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