A head-injured patient is presenting with a generalized seizure. An appropriate nursing intervention during the seizure would include which of the following?
Loosen the patient's restrictive clothing.
Open the patient's jaws to insert an oral airway.
Restrain the patient to prevent injury.
Place patient in high-Fowler's position.
The Correct Answer is A
A. Loosen the patient's restrictive clothing – This helps prevent airway obstruction and allows for better chest expansion during the seizure.
B. Open the patient’s jaws to insert an oral airway – Never attempt to force open the mouth during a seizure, as it can cause injury.
C. Restrain the patient to prevent injury – Restraining can cause further harm and should be avoided. Instead, clear the area around the patient to prevent injury.
D. Place patient in high-Fowler’s position – The patient should be placed in a side-lying position to prevent aspiration, not high-Fowler’s.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Applying a sequential compression device. – Correct Answer. SCDs help prevent venous stasis, reducing the risk of DVT in immobile patients.
B. Administering an antifibrinolytic agent. – Incorrect. Antifibrinolytics promote clot formation and are used for bleeding disorders, not DVT prevention.
C. Placing the patient on a fluid restriction. – Incorrect. Adequate hydration is important to prevent blood viscosity and clot formation.
D. Assisting the patient with passive ROM exercises. – Incorrect. Passive ROM helps circulation, but SCDs provide more effective DVT prevention.
Correct Answer is A
Explanation
A. Obtain the patient's blood glucose level between 2a.m-4a.m – Correct Answer. The Somogyi effect occurs when nighttime hypoglycemia triggers a rebound hyperglycemia in the morning. Checking the blood glucose level during the early morning hours helps confirm this phenomenon.
B. Check the patient for a change in level of consciousness between 2a.m-4a.m – Incorrect. While severe hypoglycemia can affect consciousness, the best way to confirm the Somogyi effect is through blood glucose monitoring.
C. Withhold the nighttime snack and check the glucose at 6:00 a.m. – Incorrect. A nighttime snack can help prevent the hypoglycemia that leads to the Somogyi effect.
D. Administer an increased dose of NPH insulin in the evening. – Incorrect. Increasing insulin could worsen nighttime hypoglycemia, making the Somogyi effect worse.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.