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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I give him medication so he'll be comfortable."
- This statement indicates that the parents are providing medication to ensure the child's comfort after the procedure, which is an appropriate action. It suggests that the parents are attentive to the child's needs postoperatively.
B. "I check his voiding to be sure there's no problem."
- Checking the child's voiding is important postoperatively to ensure there are no urinary retention issues or other complications related to urination. This statement reflects appropriate postoperative care and monitoring.
C. "I check his temperature."
- Monitoring the child's temperature is also a good practice postoperatively to watch for signs of infection or other complications. This statement indicates that the parents are attentive to signs of potential postoperative issues.
D. “I’ll let him decide when to return to his play activities."
- This statement suggests that the parents plan to let the child decide when to resume play activities after the surgery. However, after a surgical procedure like orchiopexy, it's important for parents to follow specific guidelines provided by healthcare providers regarding activity restrictions and return to normal activities. Allowing the child to decide may not align with the recommended postoperative care plan.
Correct Answer is D
Explanation
A. Monitor the client's hemoglobin level: Monitoring the client's hemoglobin level is not relevant during a seizure. Seizures typically do not directly affect hemoglobin levels, so this action is not appropriate.
B. Restrain the client's extremities: Restraint is generally not recommended during a seizure unless absolutely necessary for the safety of the client or others. Restraint can potentially cause injury to the client and increase agitation during the seizure.
C. Place the client in a prone position: Placing the client in a prone (face-down) position during a seizure is not recommended. This position may increase the risk of airway obstruction and compromise the client's ability to breathe effectively.
D. Record the time and length of the seizure: This is the correct answer. During a seizure, the nurse should prioritize ensuring the safety of the client and others. After ensuring safety, the nurse should document important details about the seizure, including the time it began and ended, as well as any observed symptoms or behaviors. This documentation can provide valuable information for the client's healthcare team and help guide future treatment decisions.
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