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 A
Explanation
A. Check the patient’s blood temperature. – Correct Answer. A headache and stiff neck are classic signs of meningitis. Fever is another key symptom, so checking temperature helps confirm suspicion and guides urgent intervention.
B. Administer an oral analgesic. – Incorrect. Pain management is secondary. The priority is assessing for infection (meningitis).
C. Perform a complete blood count. – Incorrect. While a CBC may show elevated WBCs, immediate assessment is more urgent.
D. Evaluate the patient’s neurological status. – Incorrect. While neurological assessment is important, confirming fever as an infection indicator is the first step.
Correct Answer is C
Explanation
A. Incorrect. Regular insulin should be given before a meal to allow time for onset; giving it after eating delays its effect, increasing hyperglycemia risk.
B. Incorrect. Administering regular insulin after breakfast is inappropriate as it may not align with meal-related glucose spikes.
C. Correct. Regular insulin has an onset of 30 minutes. Administering it at 0730 ensures optimal timing for glucose control when breakfast is eaten at 0800.
D. Incorrect. Giving insulin too early (at 0700) increases the risk of hypoglycemia before food intake.
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