The nurse is setting up the room for an admission who is being admitted for alcohol withdrawal. Which of the following should the nurse place at bedside to initiate seizure precautions? (Select all that apply)

Place the bed in the lowest position.

Keep suction setup at the bedside.

Place patient near the nurse’s station.

Keep oxygen setup at the bedside.

Place restraints at the bedside.

Answer and Explanation

Correct Answer : A,B,D

Choice A reason: Placing the bed in the lowest position is a seizure precaution for alcohol withdrawal, as seizures can cause falls. Lowering the bed minimizes injury risk by reducing fall height, addressing the high seizure risk during withdrawal due to hyperexcitability from reduced GABA activity in the brain.

Choice B reason: Keeping a suction setup at the bedside is essential for seizure precautions, as seizures during alcohol withdrawal can lead to airway obstruction from secretions or tongue biting. Suctioning maintains airway patency, preventing aspiration and ensuring oxygenation, critical given the neurological instability in withdrawal.

Choice C reason: Placing the patient near the nurse’s station enhances monitoring but is not a bedside seizure precaution. It facilitates rapid response but does not directly address immediate seizure-related risks like airway obstruction or injury, making it less critical than bedside interventions for acute seizure management.

Choice D reason: Keeping an oxygen setup at the bedside is a seizure precaution, as seizures can cause hypoxia due to prolonged muscle contractions or apnea. Oxygen administration ensures adequate cerebral oxygenation during a seizure, critical in alcohol withdrawal where neuronal hyperexcitability increases seizure risk and potential complications.

Choice E reason: Placing restraints at the bedside is not a standard seizure precaution, as restraining during a seizure can cause injury or increase agitation. In alcohol withdrawal, seizure management focuses on safety (e.g., bed height, airway protection) rather than restraint, which is only used in extreme behavioral cases, not seizures.

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Correct Answer is A

Explanation

Choice A reason: Turning the client on their side during a tonic-clonic seizure ensures airway patency by preventing aspiration of secretions. This is the first priority for safety, making it the correct action.

Choice B reason: Administering lorazepam stops seizures but is secondary to ensuring a clear airway. Safety during the ictal phase prioritizes positioning, making this incorrect as the first action.

Choice C reason: Oxygen administration is supportive but not the first action. Maintaining an open airway by positioning prevents aspiration, making this incorrect compared to turning the client.

Choice D reason: Assessing consciousness is irrelevant during the active seizure phase. Protecting the airway through positioning is the priority, making this incorrect as the first intervention.

A. Blood test for tumor markers B. Computerized tomography (CT) scan C. Phalen’s test D. Burr holes

Correct Answer is B

Explanation

Choice A reason: Blood tests for tumor markers are not primary for brain tumors, as few reliable markers exist. Imaging like CT is standard, making this incorrect for frequent diagnosis.

Choice B reason: A CT scan is the most frequently used test to diagnose brain tumors, providing detailed brain imaging to detect masses. This is standard practice, making it the correct choice.

Choice C reason: Phalen’s test diagnoses carpal tunnel syndrome, not brain tumors. It’s unrelated to neurological imaging, making this incorrect for diagnosing suspected brain tumors.

Choice D reason: Burr holes are a surgical intervention, not a diagnostic test. CT scans are non-invasive and primary for tumor detection, making this incorrect for diagnosis.

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The nurse is setting up the room for an admission who is being admitted for alcohol withdrawal. Which of the following should the nurse place at bedside to initiate seizure precautions? (Select all that apply)

Nursing Test Bank

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