The nurse is caring for a patient who was admitted for seizures. All of the following precautions should be taken to promote a safe environment except which?

Have the client use the call light if they need to get up

Pad the side rails of the client’s bed

Ensure the lights in the room are as bright as possible at all times

Avoid over stimulation and excessive activity in the client’s room

Answer and Explanation

The Correct Answer is C

A. "Have the client use the call light if they need to get up":
This is an appropriate precaution to promote safety for a patient who has seizures. It is important to encourage patients to call for assistance before getting up, especially if they are at risk for seizures. Having the patient use the call light ensures that they do not try to walk or move without supervision, which could lead to falls or injury.

B. "Pad the side rails of the client’s bed":
This is also an appropriate precaution. Padding the side rails of the bed is a common safety measure for patients who are at risk for seizures. The padding helps prevent injury if the patient moves during a seizure. Side rails should be raised during a seizure to prevent the patient from falling out of bed, but the risk of injury from the side rails themselves is minimized with padding.

C. "Ensure the lights in the room are as bright as possible at all times":
This is not an appropriate precaution. Bright lights in the room could potentially cause overstimulation, which may be a trigger for seizures in some patients. In addition, bright lights could contribute to discomfort and anxiety. Instead, the room should be kept at a comfortable, calm lighting level to help reduce stress and minimize the risk of triggering a seizure.

D. "Avoid over stimulation and excessive activity in the client’s room":
This is an appropriate precaution. Avoiding overstimulation is important for patients with seizure disorders. Excessive noise, bright lights, or other sources of stress or agitation could provoke a seizure. A calm, quiet environment helps to promote safety and reduce the risk of a seizure occurring.

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Correct Answer is B

Explanation

A. Focal awareness seizure:
Focal awareness seizures (formerly known as simple partial seizures) involve abnormal electrical activity in a specific area of the brain. These seizures typically cause motor symptoms (such as jerking or twitching in one part of the body) or sensory disturbances (like tingling or visual changes), but the person remains fully aware during the episode. The client’s presentation of a temporary loss of awareness and blank stare is more consistent with an absence seizure than a focal awareness seizure, as focal seizures do not cause a loss of consciousness.

B. Absence seizure:
Absence seizures are a type of generalized seizure often seen in children. These seizures are characterized by a sudden, brief loss of awareness, typically lasting only a few seconds. During the episode, the child may exhibit a blank stare and seem unresponsive, often without any noticeable physical movements. These seizures are often mistaken for daydreaming or inattention, but they can be diagnosed with an EEG (electroencephalogram) showing characteristic patterns. This description matches the parents’ observations of occasional episodes of loss of awareness and a blank stare.

C. Transient ischemic attack (TIA):
A TIA, also known as a mini-stroke, involves temporary neurological symptoms due to a brief disruption in blood flow to the brain. However, TIAs usually last longer than the brief episodes of loss of awareness described in this case, and they are more likely to cause focal neurological not just a transient loss of awareness. Additionally, TIAs are much less common in children and are usually associated with other risk factors like cardiovascular disease or clotting disorders.

D. Tonic clonic seizure:
Tonic-clonic seizures (formerly known as grand mal seizures) involve generalized shaking or convulsions, loss of consciousness, and can last from 1 to 3 minutes. These seizures are usually much more dramatic and prolonged compared to the brief, absence-like episodes described here. While they do involve a loss of awareness, the physical manifestations (muscle stiffening and jerking) and duration are distinctively different from the blank stare and brief loss of awareness typical of an absence seizure.

A. 2+ pedal edema bilaterally B. Blood pressure at 107/82 C. Urine output of 460 mL in 24 hours D. Disorientation

Correct Answer is D

Explanation

A. 2+ pedal edema bilaterally:
While 2+ pedal edema (a mild level of swelling in the feet and ankles) is concerning, it is not an immediate emergency in the context of hyponatremia. Edema can be seen in various conditions, including fluid retention associated with hyponatremia, but it does not require urgent intervention unless it is severe or worsening. This finding would warrant monitoring but does not require immediate action.

B. Blood pressure at 107/82:
A blood pressure reading of 107/82 mmHg is within normal limits, although on the lower end of the spectrum. This is not a concerning finding in this case and does not suggest a need for immediate intervention. The nurse should continue to monitor the client, but this blood pressure reading alone is not an emergency.
C. Urine output of 460 mL in 24 hours:
A urine output of 460 mL in 24 hours is low, indicating oliguria (decreased urine output), which can occur in cases of hyponatremia due to fluid retention. However, unless the urine output is worsening or associated with other signs of acute kidney injury or severe fluid overload, this finding alone does not require immediate intervention. It is something that should be monitored and further investigated.

D. Disorientation:
Disorientation in the elderly client with hyponatremia is a critical finding that requires immediate intervention. Hyponatremia can lead to cerebral edema (brain swelling), which results in altered mental status, including confusion, disorientation, or seizures. These symptoms indicate that the hyponatremia may be severe enough to affect neurological function and requires prompt correction to avoid further complications, such as coma or permanent brain damage. Immediate intervention to address the underlying cause of the hyponatremia and restore sodium balance is crucial.

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The nurse is caring for a patient who was admitted for seizures. All of the following precautions should be taken to promote a safe environment except which?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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