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. Patches of baldness: Patches of baldness on the scalp could be indicative of conditions like alopecia areata, a disorder characterized by hair loss in patches. However, it is not a typical manifestation of pediculosis capitis, which primarily presents with scalp itchiness due to lice bites rather than hair loss.
B. Blisters on the scalp: Blisters on the scalp may suggest other conditions such as herpes simplex infection or contact dermatitis. While scratching from head lice infestation could lead to skin irritation, blisters are not a common presentation of pediculosis capitis.
C. Dry patches on the scalp: Dry patches on the scalp might be caused by conditions like seborrheic dermatitis or eczema. While scalp dryness can occur with pediculosis capitis due to irritation from scratching, it is not a specific symptom associated with head lice infestation.
D. Reports of scalp itchiness: Scalp itchiness is a hallmark symptom of pediculosis capitis. It occurs as a result of lice bites and the body's inflammatory response to their saliva. It is the most characteristic and common manifestation of head lice infestation and often prompts further examination for the presence of lice or their eggs (nits).
Correct Answer is C
Explanation
A. Drooling - Drooling is not typically associated with intussusception. Intussusception is a condition where one portion of the intestine telescopes into another, leading to bowel obstruction and subsequent symptoms such as abdominal pain, vomiting, and "currant jelly" stools.
B. Increased appetite - Increased appetite is unlikely in a toddler with intussusception. Instead, affected toddlers may experience symptoms such as abdominal pain, vomiting, and lethargy, which can lead to decreased appetite.
C. Mucus in stools - Mucus in stools is a characteristic finding in intussusception. As the telescoping of the intestine causes irritation and inflammation, mucus may be passed in the stool along with blood and, in some cases, a characteristic "currant jelly" appearance.
D. Jaundice - Jaundice is not a typical manifestation of intussusception. It may be present in conditions affecting the liver or bile ducts, such as biliary atresia or obstructive jaundice, but it is not a direct symptom of intussusception.
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