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.
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Related Questions
Correct Answer is C
Explanation
A. Incorrect. Regular insulin (short-acting) and Humulin N (intermediate-acting) can be mixed.
B. Incorrect. Regular insulin and Novolin N are compatible.
C. Correct. Lantus (glargine) is a long-acting insulin that should never be mixed with other insulins.
D. Incorrect. Humulin R (short-acting) and Novolin N (intermediate-acting) can be mixed.
Correct Answer is B
Explanation
A. High glucose levels cause the body to use proteins for energy, causing lactic acidosis – While hyperglycemia can lead to ketosis, it does not directly cause lactic acidosis.
B. Chronic elevated blood glucose levels damage cells and cause long-term chronic organ dysfunction – Hyperglycemia leads to complications such as neuropathy, nephropathy, and retinopathy, making glucose control essential.
C. Early identification of hypoglycemia is easier to treat resulting in better outcomes – While important, the primary reason for frequent monitoring is to prevent long-term complications.
D. Carbohydrates are constantly being converted to glucose and utilized for extra energy stores – This statement is not specific to diabetes management.
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