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 questions)
1. Which of the following is a common intrinsic fall risk factor?
Terms in this Study Set(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.
Questions in this Study Set(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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