Questions and Answers
A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? (Select all that apply)
Which change in vital signs would occur if increased intracranial pressure (ICP) is rising?
Which position would require intervention by the nurse for a client with increased intracranial pressure (ICP)?
Study Notes
Seizure Precautions
- Implement padded side rails to prevent injury during seizures.
- Maintain an airway at the bedside to ensure airway patency if needed.
- Have oxygen equipment nearby for potential respiratory needs during a seizure.
- Place suction equipment at the bedside to clear secretions if the patient becomes unable to do so.
Intracranial Pressure (ICP) Changes
- Increased ICP may show distinct vital sign trends: increased temperature, increased blood pressure, decreased pulse, and decreased respirations.
- Changes in vital signs are often late indicators of rising ICP.
Positioning for Increased ICP
- Proper positioning is crucial; head should be in a neutral, midline position.
- Avoid head turning to the side, which can increase ICP.
- Elevate the head of the bed to 30 to 45 degrees to enhance venous drainage from the cranium.
ICP Management Understanding
- A patient recovering from a head injury demonstrates understanding of ICP prevention by exhaling during repositioning.
- Activities that increase ICP, such as blowing the nose, isometric exercises, and vigorous coughing, should be avoided.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
Test your knowledge on essential seizure precautions for clients with seizure disorders. This quiz covers crucial nursing interventions to ensure safety during episodes. Select all appropriate actions for effective patient care.