Question

A nurse is caring for a client who has a history of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take?

a.Assess hourly for a spike in blood pressure.
b.Keep the client on bed rest.
c.Keep a padded tongue blade at the bedside.
d.Establish IV access.

Answer 1

The nurse should establish IV access, keep the client on bed rest, and assess for a spike in blood pressure when caring for a client with a history of status epilepticus.

Step-by-step explanation:

When caring for a client with a history of status epilepticus, the nurse should take the following actions:

• Establish IV access: This is important for administering anticonvulsant medications during a seizure.
• Keep the client on bed rest: This helps prevent injury during a seizure episode.
• Assess hourly for a spike in blood pressure: High blood pressure can be a sign of seizure activity or medication side effects.

It is not necessary to keep a padded tongue blade at the bedside as it can pose a risk of airway obstruction.