Difficulty: Medium
Average Score: 84%
Simulated
Passage / Scenario
Nurses' Notes0800:
Client is alert and oriented to person, place, and time. Seizure pads placed on the client's bed. Suction equipment is at the client's bedside and functioning. Oxygen equipment is at the client's bedside.
1000:
Client is in bed and reports experiencing an aura, followed by generalized jerking contractions of arms and legs. Client incontinent of urine and unresponsive to commands.
1004:
Client's jerking contractions of arms and legs continues. Yellow, watery emesis approximately 45 mL on gown; 2 to 5-second-long periods of apnea.
Vital Signs
1002:
Heart rate 86/min Respiratory rate 12/min
Oxygen saturation 86% on room air
A nurse is caring for a client who has a seizure disorder. (Select all that apply.)
Correct answer
A,C,E
Rationale
Correct Answer: A, C, E
Rationale:
A: Administering supplemental oxygen helps maintain oxygen levels during a seizure, preventing hypoxia.
C: Timing the seizure duration is crucial for accurate documentation and evaluating the effectiveness of interventions.
E: Turning the client to the side helps prevent aspiration and ensures the airway remains clear.
Incorrect Choices:
B: Restraining the client during a seizure can cause harm and increase the risk of injury.
D: Placing a tongue depressor in the client's mouth can lead to airway obstruction and injury.
In summary, administering oxygen, timing the seizure, and turning the client are essential interventions, while restraining and using tongue depressors are potentially harmful actions.
Rationale:
A: Administering supplemental oxygen helps maintain oxygen levels during a seizure, preventing hypoxia.
C: Timing the seizure duration is crucial for accurate documentation and evaluating the effectiveness of interventions.
E: Turning the client to the side helps prevent aspiration and ensures the airway remains clear.
Incorrect Choices:
B: Restraining the client during a seizure can cause harm and increase the risk of injury.
D: Placing a tongue depressor in the client's mouth can lead to airway obstruction and injury.
In summary, administering oxygen, timing the seizure, and turning the client are essential interventions, while restraining and using tongue depressors are potentially harmful actions.