Correct Answer: C

Rationale: Instructing the client to take deep, rhythmic breaths can help in managing pain by promoting relaxation and reducing muscle tension. However, for localized back pain, direct application of cold or heat is often more effective. Encouraging the client to apply a heating pad for 2 hours at a time can provide relief, but prolonged heat application (beyond 20-30 minutes) may increase inflammation or discomfort. Applying an ice pack to the client's back for 1 hour is effective in reducing inflammation and numbing mild back pain, though 20-30 minutes is typically recommended to avoid skin damage. This is still the best choice for immediate relief. Removing distractions can support relaxation but does not directly address localized pain.

Correct Answer: B,C,D

Rationale: When providing client education about the medication, the nurse focuses on informing the client about the purpose, dosage, and potential side effects of the medication. This step is crucial for ensuring that the client understands their treatment plan and can adhere to it properly. However, this is not the appropriate time to compare the medication administration record (MAR) against the medication container. The comparison should be done during the actual medication administration process to prevent errors. At the client's bedside before administering the medication, the nurse should compare the MAR against the medication container. This step is part of the 'three checks' process, which helps ensure that the correct medication is given to the right patient at the right time. By verifying the medication at the bedside, the nurse can catch any discrepancies and prevent potential medication errors. Before selecting the medication container, the nurse should compare the MAR against the medication container. This is the first of the 'three checks' and is essential for ensuring that the correct medication is selected from the storage area. This step helps prevent errors that could occur if the wrong medication is chosen. While removing medication from the container, the nurse should again compare the MAR against the medication container. This is the second of the 'three checks' and serves as an additional safeguard to ensure that the correct medication is being prepared for administration. This step helps catch any errors that might have been missed during the initial selection. When documenting the medication administration, the nurse records the details of the medication given, including the time, dosage, and any observations. While accurate documentation is crucial for maintaining a complete medical record, this is not the appropriate time to compare the MAR against the medication container. The comparison should be done during the medication administration process to ensure accuracy.

Correct Answer: C

Rationale: Lifting the client to the bed with assistance is not recommended during a seizure. Moving the client can increase the risk of injury to both the client and the nurse. The primary focus should be on ensuring the client's safety by preventing injury from nearby objects and allowing the seizure to run its course. Turning the client onto their back is not advisable during a seizure. This position can increase the risk of airway obstruction and aspiration. Instead, the client should be turned onto their side to maintain an open airway and allow any secretions to drain from the mouth, reducing the risk of aspiration. Clearing the nearby area of furniture is the most appropriate action. This helps to prevent the client from injuring themselves on hard or sharp objects during the seizure. Ensuring a safe environment is a key priority in managing a seizure, as it minimizes the risk of physical harm. Placing a tongue depressor in the client's mouth is an outdated and dangerous practice. It can cause injury to the client's teeth, mouth, or airway. There is also a risk of the client biting down and breaking the depressor, leading to choking hazards. Modern seizure management guidelines strongly advise against placing any objects in the client's mouth during a seizure.

Correct Answer: D

Rationale: Larger catheters (20 French) increase trauma risk; full bags risk backflow; disconnecting breaks sterility. Keeping the bag below bladder level prevents urine backflow, reducing infection risk.

Correct Answer: C

Rationale: Having a padded tongue blade available at the client's bedside is not recommended for seizure management. Inserting any object into a patient's mouth during a seizure can cause injury to the teeth, gums, or jaw. Current guidelines advise against placing anything in the mouth of a person having a seizure. Instead, focus should be on ensuring the patient's safety by turning them on their side to maintain an open airway and prevent aspiration. Keeping the four side rails down when the client is in bed is not advisable for a client with a seizure disorder.
To prevent injury during a seizure, it is important to keep the side rails up and padded. This helps prevent the client from falling out of bed and sustaining injuries. Additionally, the bed should be kept in its lowest position to minimize the risk of injury from falls. Keeping suction equipment available in the client's room is crucial for managing a client with a seizure disorder. During a seizure, there is a risk of aspiration due to excessive salivation or vomiting. Having suction equipment readily available allows the nurse to quickly clear the client's airway, reducing the risk of aspiration and ensuring the client can breathe properly. Having wire cutters available at the client's bedside is not typically necessary for managing a seizure disorder. They are sometimes mentioned in the context of clients with Vagus Nerve Stimulators (VNS), where wire cutters might be used in an emergency to cut the VNS wire. However, this is a rare situation and not a standard precaution for all clients with seizure disorders.