Which nursing action would be appropriate to protect a patient during a seizure? (Select all that apply)

Placing a pad under the patient's head after guiding them to the floor from a standing position

Avoiding placing any objects in the mouth when the patient's teeth are clenched

Guiding the patient to the bed from the floor during a seizure

Turning the patient to one side, having a slightly forward-tilted head

Using supporting pillows for the patient who is on bed

Answer and Explanation

Correct Answer : A,B,D,E

A. Placing a pad under the patient's head after guiding them to the floor from a standing position: This helps to protect the head from injury if the patient falls. However, guiding the patient to the floor should only be done if it is safe and possible to do so without causing further injury.
B. Avoiding placing any objects in the mouth when the patient's teeth are clenched: This prevents the risk of choking or damaging the patient's teeth. It is a common safety measure during seizures.
C. Guiding the patient to the bed from the floor during a seizure: This action is not appropriate during the seizure itself as it may cause injury or disrupt the patient's movement. Instead, the patient should remain in a safe position until the seizure ends.
D. Turning the patient to one side, having a slightly forward-tilted head: This helps to prevent aspiration and facilitates easier breathing during and after the seizure.
E. Using supporting pillows for the patient who is on bed: This helps to protect the patient from injury and provides support, ensuring safety during and after the seizure.

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Correct Answer is B

Explanation

A. Use a square knot. Using a square knot is not recommended for securing restraints because it can be difficult to quickly release in an emergency. Instead, restraints should be secured with a quick-release tie to ensure they can be removed promptly if necessary.
B. Assess the extremity for circulation and neurological integrity every 2 hours. Regular assessment of the extremity is essential to ensure that the restraint is not impairing circulation or causing nerve damage. This frequent monitoring helps prevent complications and ensures the client’s safety.
C. Secure the restraint to the side rail. Securing restraints to the side rail is not recommended as it can cause injury or entrapment. The restraint should be secured to the bed frame or a fixed part of the bed that does not move or pose a risk to the client.
D. Assess restraints and skin integrity every 12 hours. Assessing restraints and skin integrity every 12 hours is inadequate. More frequent assessments, such as every 2 hours, are necessary to prevent skin breakdown and ensure that the restraints are not causing harm.

A. Placing a high risk for falls armband on the patient B. Checking on the patient once a shift C. Keep the bed in the lowest position D. Placing all four side rails in the "up" position E. Maintain call light within reach of the patient

Correct Answer is ["A","C","E"]

Explanation

A. Placing a high risk for falls armband on the patient: An armband alerts all healthcare providers to the patient's fall risk, helping to ensure appropriate precautions are taken.
B. Checking on the patient once a shift: This is not sufficient; patients on fall precautions should be checked more frequently, such as every hour or according to the facility's protocol, to ensure their safety.
C. Keep the bed in the lowest position: Keeping the bed at its lowest position reduces the risk of injury from falls and helps ensure the patient can easily get in and out of bed.
D. Placing all four side rails in the "up" position: Using all four side rails is not recommended as it can increase the risk of entrapment and may not be effective in preventing falls. Side rails should be used appropriately and in accordance with safety protocols.
E. Maintain call light within reach of the patient: Ensuring the call light is within reach helps the patient call for assistance if needed, which can help prevent falls.

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Which nursing action would be appropriate to protect a patient during a seizure? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is essential when restraints are applied to a client?

Correct Answer is B

Explanation

The client has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include: (Select All that Apply)

Correct Answer is ["A","C","E"]

Explanation

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