The nurse is caring for a client with an ileostomy because of inflammatory bowel disease. Which assessment findings indicate to the nurse that the ileostomy is functioning as expected? Select all that apply.

Choice A Reason:

Suction equipment at the bedside.

Having suction equipment at the bedside is crucial for a client with status epilepticus. During a seizure, there is a risk of aspiration due to excessive salivation or vomiting. Suction equipment allows the nurse to quickly clear the airway, preventing aspiration and ensuring the client can breathe properly. This precaution is essential to maintain the client’s airway and prevent complications such as aspiration pneumonia.

Choice B Reason:

Continuous sedation.

Continuous sedation is not typically a standard precaution for all clients with status epilepticus. While sedation may be necessary in some cases to control seizures, it is not a universal precaution. The primary goal is to stop the seizure activity and stabilize the client. Continuous sedation may be used in specific situations under close medical supervision, but it is not a general precaution that nurses implement for all clients with status epilepticus.

Choice C Reason:

Side rails padded.

Padding the side rails of the bed is an important precaution to prevent injury during a seizure. Clients experiencing seizures may have uncontrolled movements, which can lead to injury if they hit the hard surfaces of the bed. Padded side rails help to cushion these impacts, reducing the risk of bruises, cuts, or fractures. This precaution is essential for ensuring the client’s safety during seizure activity.

Choice D Reason:

Bed in low position.

Keeping the bed in a low position is another important safety measure. If a client with status epilepticus were to fall out of bed during a seizure, the lower height reduces the risk of serious injury. This precaution helps to minimize the impact of any potential falls, ensuring the client’s safety. It is a simple yet effective measure to prevent harm during seizure episodes.

Choice E Reason:

Intravenous (IV) access.

Establishing intravenous (IV) access is critical for a client with status epilepticus. IV access allows for the rapid administration of medications needed to control seizures and manage the client’s condition. In an emergency, quick access to the bloodstream is essential for delivering life-saving treatments. This precaution ensures that the medical team can promptly and effectively intervene to stop the seizure activity.

Choice A: Periodic Nystagmus

Nystagmus, which is characterized by involuntary eye movements, can be a symptom of various neurological conditions, including bacterial meningitis. However, it is not typically an immediate concern compared to other symptoms. Nystagmus indicates potential issues with the brainstem or cerebellum, but it does not directly threaten the patient’s life or indicate a rapid deterioration in condition. Therefore, while it is important to monitor, it is not the most urgent finding.

Choice B: Severe Unrelenting Headaches

Severe headaches are a common symptom of bacterial meningitis due to the inflammation of the meninges. While they are extremely painful and distressing for the patient, they are not as immediately life-threatening as a decreased level of consciousness. Headaches indicate increased intracranial pressure, which is serious, but the priority is to address symptoms that indicate a more rapid decline in neurological function.

Choice C: Photophobia During the Day

Photophobia, or sensitivity to light, is another common symptom of meningitis. It results from the irritation of the meninges and is often accompanied by headaches. While photophobia can be very uncomfortable and indicative of meningitis, it is not an immediate concern compared to a decreased level of consciousness. Photophobia does not directly indicate a life-threatening situation.

Choice D: Decreased Level of Consciousness

A decreased level of consciousness is the most immediate concern for a nurse caring for a patient with bacterial meningitis. This symptom indicates a significant and potentially rapid decline in the patient’s neurological status. It can be a sign of increased intracranial pressure, brain swelling, or other severe complications. Immediate medical intervention is required to prevent further deterioration and potential fatality. Monitoring and addressing changes in consciousness are critical in managing bacterial meningitis effectively.