You have a patient who has a brain tumor and is at risk for seizures. In the patient's plan of care you incorporate seizure precautions. Select the 3 choices below for all the proper steps to take in initiating seizure precautions. (Select All that Apply.)

Bed in highest position

Remove restrictive objects or clothing from patients’ body

Remove all pillows from the patient's head

Oxygen and suction at bedside

Padded bed rails

Answer and Explanation

Correct Answer : B,D,E

A. Bed in highest position:
The height of the bed is not directly related to seizure precautions.

B. Remove restrictive objects or clothing from patients’ body:
This is important to prevent injury during a seizure episode.

C. Remove all pillows from the patient's head:
While it's generally a good practice to remove pillows to prevent suffocation or obstruction, it's not specifically related to seizure precautions.

D. Oxygen and suction at bedside:
Oxygen and suction should be readily available to support the patient's respiratory status and clear any secretions or vomit during or after a seizure.

E. Padded bed rails:
Padded bed rails can help prevent injury if the patient thrashes or moves violently during a seizure.

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Correct Answer is B

Explanation

A. Shingles: This is a viral infection caused by the varicella-zoster virus, which also causes chickenpox. It typically manifests as a painful rash that develops into fluid-filled blisters.

B. Athlete's foot: This is a fungal infection of the skin on the feet, particularly between the toes. It causes itching, burning, and cracked, flaking skin.

C. Fever blister: Also known as a cold sore, this is a viral infection caused by the herpes simplex virus. It typically appears as a cluster of small, fluid-filled blisters on or around the lips.

D. Pinworms: This is a parasitic infection caused by tiny, white worms that infect the intestines. It commonly causes anal itching, particularly at night, due to the female worms laying eggs around the anal area.

A. Place the child in a side-lying position. B. Restrain the child's arms. C. Elevate the child's legs on a pillow. D. Insert a padded tongue blade into the child's mouth.

Correct Answer is A

Explanation

A. Place the child in a side-lying position.

This is the correct action to take during a seizure to prevent aspiration and maintain an open airway. Placing the child in a side-lying position helps to prevent choking or aspiration if vomiting occurs and allows saliva or other fluids to drain out of the mouth instead of being inhaled into the lungs.

B. Restrain the child's arms.

Restraining the child's arms is not recommended during a seizure. It can potentially cause injury to the child or the person trying to restrain them. It may also exacerbate muscle spasms and increase the risk of injury during the seizure.

C. Elevate the child's legs on a pillow.

Elevating the child's legs on a pillow is not necessary during a seizure and is not a recommended intervention. It does not address the immediate needs of the child during a seizure, such as maintaining an open airway and preventing injury.

D. Insert a padded tongue blade into the child's mouth.

Inserting anything into the child's mouth during a seizure, including a tongue blade, is strongly discouraged. It can cause injury to the child's teeth, gums, or oral tissues and increase the risk of choking or aspiration. It may also result in the nurse getting bitten during the seizure. Maintaining a clear airway and ensuring the child's safety are the priorities during a seizure, and inserting objects into the mouth can interfere with these goals.

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You have a patient who has a brain tumor and is at risk for seizures. In the patient's plan of care you incorporate seizure precautions. Select the 3 choices below for all the proper steps to take in initiating seizure precautions. (Select All that Apply.)

Nursing Test Bank

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Correct Answer is A

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