A client arrives at the emergency room experiencing status epilepticus. Which of the following interventions should the nurse anticipate performing first for this client?

administer diazepam via intravenous push

prepare to administer a glucocorticoid orally

monitor the client's cardiac rhythm via telemetry

assess the client's neurological status every hour

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the correct answer. Administering diazepam via intravenous push is the first-line treatment for status epilepticus to quickly control and terminate the seizure activity. Rapid intervention is crucial to prevent prolonged seizures and potential complications.

Choice B reason: Preparing to administer a glucocorticoid orally is not the immediate first step in managing status epilepticus. Glucocorticoids may be used in specific cases, but the priority is to stop the seizure with fast-acting medications like diazepam.

Choice C reason: Monitoring the client's cardiac rhythm via telemetry is important, especially given the potential cardiovascular effects of seizures and medications. However, it is not the immediate first action. Controlling the seizure takes precedence.

Choice D reason: Assessing the client's neurological status every hour is part of ongoing care, but it is not the first intervention. The immediate goal is to terminate the seizure activity to prevent further neurological damage.

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Correct Answer is C

Explanation

Choice A reason: Keeping the fluorescent ceiling light on at night can disrupt sleep and is not necessary for preventing falls. Nightlights or bedside lamps are more appropriate for providing enough light to move around safely without disturbing sleep.

Choice B reason: Keeping the walker at the end of the bed is not a practical or safe placement. It should be within easy reach of the client to ensure it can be used immediately upon standing to prevent falls.

Choice C reason: This is the correct answer. Placing a bath seat in the shower is an excellent strategy for preventing falls. It allows the client to sit while bathing, reducing the risk of slipping and falling in the shower, which is a common hazard area.

Choice D reason: Placing an area rug at the entry of the bathroom can create a tripping hazard. It is important to avoid loose rugs or mats that could cause falls, especially in areas where water might make the floor slippery.

A. WBC count 8,000/mm³ B. hemoglobin 16 g/dL C. serum albumin 3.2 g/dL D. INR 0.9

Correct Answer is C

Explanation

Choice A reason: A WBC count of 8,000/mm³ falls within the normal range (4,000-11,000/mm³) and does not indicate a specific risk for delayed wound healing. It helps assess the immune response but is not a direct marker for nutrition or tissue repair.

Choice B reason: A hemoglobin level of 16 g/dL is within the normal range (13.8-17.2 g/dL for men, 12.1-15.1 g/dL for women) and indicates adequate oxygen-carrying capacity. While essential for overall health, it does not directly correlate with the risk of delayed wound healing in this context.

Choice C reason: This is the correct answer. Serum albumin levels are a marker of nutritional status. A level of 3.2 g/dL is on the lower side of the normal range (3.5-5.0 g/dL) and indicates potential malnutrition, which can impair wound healing by limiting the availability of necessary proteins and nutrients for tissue repair.

Choice D reason: An INR (International Normalized Ratio) of 0.9 is within the normal range (0.8-1.2) and reflects normal blood clotting. While important for understanding coagulation status, it does not indicate a direct risk for delayed wound healing related to nutrition or protein levels.

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A client arrives at the emergency room experiencing status epilepticus. Which of the following interventions should the nurse anticipate performing first for this client?

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