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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Give the patient access to a video about diabetes. – Incorrect. Educational materials are helpful but should be provided after assessing the patient's current knowledge level.
B. Determine what the patient knows about managing diabetes. – Correct Answer. The first step in teaching is to assess the patient's baseline knowledge to tailor the education to their needs.
C. Establish short-term, realistic goals for the patient. – Incorrect. Goal-setting is important but should come after assessing the patient’s knowledge and readiness to learn.
D. Evaluate the effectiveness of the patient's admission teaching plan. – Incorrect. The nurse should first determine what new information needs to be taught before evaluating previous teaching.
Correct Answer is D
Explanation
A. Eat plenty of fresh fruits and vegetables. – Incorrect. Raw fruits and vegetables can harbor bacteria, increasing the risk of infection for a patient with neutropenia.
B. Take temperature weekly. – Incorrect. Patients with neutropenia should check their temperature daily, as fever may be the first sign of infection.
C. Perform mild exercise, such as gardening. – Incorrect. Gardening exposes the patient to soilborne fungi and bacteria, which can be harmful.
D. Avoid crowds. – Correct Answer. Neutropenic patients are highly susceptible to infections, so avoiding crowds helps reduce the risk of exposure to contagious illnesses.
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