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Patient Data

Exhibits

Which nursing interventions should the nurse prioritize during the postictal period?

Monitor airway and oxygen saturation

Assess neurological status and level of consciousness

Check vital signs after 3 hours

Reorient the client as needed

Encourage oral intake immediately

Answer and Explanation

Correct Answer : A,B,D

Rationale for Correct Choices:

Monitor airway and oxygen saturation: The client was apneic during the seizure and required assisted ventilation. Continuous monitoring ensures that oxygenation is adequate and that respiratory complications are promptly detected.
Assess neurological status and level of consciousness: The postictal period is associated with confusion, lethargy, or altered mental status. Frequent neurological assessments allow the nurse to identify complications such as ongoing seizure activity or intracranial injury.
Reorient the client as needed: Postictal clients may be disoriented or confused. Reorienting the client helps reduce anxiety, ensures safety, and facilitates communication and recovery.

Rationale for Incorrect Choices:

Check vital signs after 3 hours: Vital signs should be assessed immediately and frequently after a seizure, not delayed, because changes can indicate complications such as hypoxia, hypotension, or arrhythmias.
Encourage oral intake immediately: The client may have an impaired swallow reflex or nausea in the postictal period, putting them at risk for aspiration. Oral intake should be delayed until fully alert and able to swallow safely.

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Correct Answer is B

Explanation

Rationale:
A. Urine is pale pink with no observable blood clots: Light hematuria may occur after lithotripsy, but absence of clots alone does not confirm that the stones were effectively fragmented or removed.

B. Stone fragments are collected when straining the client's urine: The presence of stone fragments indicates that the lithotripsy successfully broke up the calculi, allowing them to pass or be collected. This directly demonstrates procedural effectiveness.

C. Client denies urinary frequency, urgency, or dysuria: Relief of urinary symptoms may occur gradually and does not immediately confirm that the stones were effectively fragmented or removed.

D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits: Normal renal function is important, but it does not specifically indicate that the lithotripsy procedure successfully fragmented the stones.

A. "I will avoid sitting and crossing my legs." B. “I will lift weights every other day." C. "I will be able to stand as long as my legs do not hurt." D. "I will need to get someone to walk my dog."

Correct Answer is A

Explanation

Rationale:
A. "I will avoid sitting and crossing my legs.": Avoiding prolonged sitting and refraining from crossing the legs helps prevent venous stasis and promotes proper blood return from the lower extremities, which is essential in managing chronic venous insufficiency.

B. “I will lift weights every other day.": Strenuous weight lifting increases intra-abdominal and venous pressure, which can exacerbate venous insufficiency and is not recommended as routine home care.

C. "I will be able to stand as long as my legs do not hurt.": Prolonged standing can worsen venous pooling and edema, even if discomfort is not immediately felt.

D. "I will need to get someone to walk my dog.": While walking can promote circulation, delegating all walking is unnecessary. Moderate, regular ambulation is encouraged for venous return rather than complete avoidance of activity.

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Patient Data Exhibits Which nursing interventions should the nurse prioritize during the postictal period?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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Patient Data

Exhibits

Which nursing interventions should the nurse prioritize during the postictal period?