NCLEX fall and seizure precautions cheat sheet
A comprehensive NCLEX cheat sheet focusing on fall and seizure precautions, designed to help nursing students review crucial safety protocols and nursing actions.
Quiz(32 spørgsmål)
1. Which of the following is a common intrinsic fall risk factor?
Begreber i dette studiesæt(32)
Fall Precautions(16)
What are common fall risk factors?
Age, medication side effects, mobility impairments, cognitive deficits, environmental hazards.
True or False: Bedside rails reduce fall risk.
False. Bedside rails can increase the risk of entrapment or falls.
Fill in the blank: Assess patient's _______ status regularly.
cognitive
What should you ensure is within reach?
Call light, personal items, and assistive devices.
List two interventions for preventing falls.
- Use non-slip footwear. - Keep the environment clutter-free.
What is the importance of hourly rounding?
Reduces fall rates by addressing patient needs proactively.
Cause → Effect: Poor lighting leads to _____
Increased fall risk due to visibility issues.
What should be done before ambulation?
Assess patient's strength and balance, and use assistive devices as needed.
What is a fall prevention tool?
Fall risk assessment scales (e.g., Morse Scale).
True or False: Side effects of medication can contribute to falls.
True. Sedatives and antihypertensives can impair balance and coordination.
Name two environmental modifications to prevent falls.
- Install grab bars. - Use motion-sensor lights.
What should you do if a patient falls?
Assess for injuries, notify the physician, and document the incident.
What is a key patient education point?
Encourage patients to call for assistance before getting up.
Comparison: Intrinsic vs Extrinsic fall risk factors.
Intrinsic: Personal health conditions. Extrinsic: Environmental hazards.
What is the recommended position for patients at high fall risk?
Keep bed in low position.
What is the goal of a fall prevention plan?
To minimize the risk of falls and promote patient safety.
Seizure Precautions(16)
What are seizure precautions?
Measures to prevent injury during a seizure, including environmental modifications and patient monitoring.
True or False: Always place a tongue blade in a patient's mouth during a seizure.
False. This can cause injury; do not place anything in the mouth.
Key safety measures for seizure patients?
Keep bed in lowest position, side rails up, and remove dangerous objects.
What to do during a seizure?
Protect the patient from harm, note duration, and position them on their side postictally.
Fill in the blank: Always have _______ at bedside for seizure patients.
Suction equipment and oxygen.
Cause → Effect: What happens if a patient is not monitored during a seizure?
Increased risk of injury or aspiration.
What should be documented after a seizure?
Time of seizure, duration, behavior before/during/after, and any interventions provided.
Seizure types: Generalized vs Partial.
Generalized affects both hemispheres; partial affects one hemisphere.
What is the purpose of a seizure action plan?
To provide specific instructions for caregivers during and after a seizure.
Signs of a pending seizure?
Aura, unusual sensations, changes in behavior.
True or False: Patients should be restrained during a seizure.
False. Restraints can cause injury; allow the seizure to occur freely.
How to protect a patient during a seizure?
Clear the area, cushion the head, and do not hold them down.
What is postictal state?
The period after a seizure characterized by confusion, exhaustion, and possible headache.
Seizure triggers include:
Stress, flashing lights, fatigue, and certain medications.
Fill in the blank: Seizure patients should wear a _______.
Medical alert bracelet.
What to monitor post-seizure?
Vital signs, neurological status, and level of consciousness.
Spørgsmål i dette studiesæt(32)
1. Which of the following is a common intrinsic fall risk factor?
2. What is the primary purpose of seizure precautions?
3. True or False: Placing a patient in a high position in bed is safer for fall prevention.
4. Which action should be avoided during a seizure?
5. Fill in the blank: Always ensure that the patient’s ______ is within reach.
6. What is the best position for a patient after a seizure?
7. Which of the following is NOT an appropriate intervention for preventing falls?
8. Which of the following is NOT a key safety measure for seizure patients?
9. What is the primary purpose of hourly rounding?
10. What is a common sign indicating a seizure may occur?
11. Cause → Effect: Excessive sedation from medication leads to _____
12. During a seizure, the nurse should prioritize which action?
13. What should you assess before ambulating a patient?
14. What should be included in a seizure action plan?
15. Which of the following is a fall prevention tool?
16. What is the postictal state?
17. True or False: Environmental modifications can help prevent falls.
18. Which of the following is a common seizure trigger?
19. Which of the following is an extrinsic fall risk factor?
20. What should be documented after a seizure?
21. What should a nurse do immediately after a patient falls?
22. What is a medical alert bracelet used for?
23. What is a key point in patient education regarding fall prevention?
24. Which of the following is an appropriate intervention during a seizure?
25. Comparison: Which of the following correctly describes intrinsic vs. extrinsic fall risk factors?
26. What should be monitored immediately after a seizure?
27. What is the goal of a fall prevention plan?
28. What happens if a patient is not monitored during a seizure?
29. What is one example of a common environmental modification to prevent falls?
30. True or False: Patients should be allowed to fall during a seizure to avoid injury.
31. Which of the following interventions is most effective in reducing fall risks for elderly patients?
32. Which of the following actions is essential for a nurse to take when a patient experiences a seizure?
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