The nurse is caring for a client who has seizure precautions. ...

[s.tung]

The nurse is caring for a client who has seizure precautions. Which actions by the nurse are appropriate for these precautions?
 
  Select all that apply.
  1. Padding the bed around the head, foot, and side rails
  2. Placing functional oral suction equipment in the room
  3. Placing extremity restraints in the room for use if the client has a seizure
  4. Keeping pillows handy to protect the client's head
  5. Taping a bite block to the wall to protect the client from biting his or her tongue

Question 2

The nurse is providing care to a client who has an order for a jacket restraint. Which action by the nurse is appropriate when applying this restraint to the client?
 
  1. Placing the vest with the opening on the side
  2. Pulling the tie on the end of the vest flap across the chest and placing it through the slit on the same side of the chest
  3. Using a slipknot to secure the tie around the solid leg of the bed frame
  4. Using a half-bow knot to secure the tie around the movable bed frame

[vish98]

Answer to Question 1

Correct Answer: 1,2,4
Padding the bed will protect the client from injury if clonic tonic movement of the extremities occurs during a seizure. Suctioning equipment will allow the nurse to clear the airway after the seizure. Pillows are useful in helping the client protect the head from banging on the floor if he is not in bed when a seizure occurs. The client's extremities should never be restrained during a seizure. Nothing should be inserted into the client's mouth during a seizure, so bite blocks are not necessary.

Answer to Question 2

Correct Answer: 4

The nurse should tie the restraint to the movable part of the bed frame to avoid injuring the client if the head of the bed is raised or lowered. Use a half-bow knot, which is easy and quick to open. The vest is placed with the opening in the front or the back depending on the type of restraint used. The tie on the end of the vest is pulled across the chest and placed in the slit at the opposite side of the chest.

[s.tung]

TYSM

[bitingbit]

Excellent