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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Stopping an antibiotic once feeling better is incorrect and can lead to incomplete treatment of the infection and antibiotic resistance. Patients should complete the full course of antibiotics as prescribed.
Choice B reason:
Skipping a dose if 30 minutes late is incorrect advice. Most medications have a dosing window and can be taken even if slightly late. Patients should be advised to take the dose as soon as remembered unless it is almost time for the next dose.
Choice C reason:
Parenteral medications, such as injections, do not need to be taken with food. This instruction is more applicable to oral medications that can cause gastrointestinal upset.
Choice D reason:
Rotating the sites for a transdermal patch is correct and indicates effective teaching. This practice helps prevent skin irritation and ensures proper absorption of the medication.
Correct Answer is C
Explanation
Choice A reason: A hemorrhagic stroke occurs due to bleeding in the brain, often from a burst blood vessel. While individuals with cardiovascular disease might have risk factors, atrial fibrillation primarily increases the risk for strokes caused by clots, not bleeding.
Choice B reason: A thrombotic stroke is caused by a clot that forms within the blood vessels of the brain. While cardiovascular disease can contribute to thrombosis, atrial fibrillation more commonly leads to embolic strokes due to clots forming in the heart and traveling to the brain.
Choice C reason: This is the correct answer. Atrial fibrillation increases the risk of embolic strokes because it can cause blood clots to form in the heart. These clots can travel to the brain and cause an embolic stroke, which is why patients with atrial fibrillation are often on anticoagulant therapy.
Choice D reason: A subarachnoid stroke involves bleeding in the space between the brain and the surrounding membrane. It is typically associated with aneurysms or head injury, rather than atrial fibrillation. This choice does not align with the client’s condition.
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