A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

Gently restrain the client’s extremities

Place the client on a BiPAP machine for oxygenation

Place a pillow under the client’s head

Insert a padded tongue blade into the client’s mouth

Answer and Explanation

The Correct Answer is C

Choice A reason: Gently restraining extremities during a tonic-clonic seizure is unsafe, as it can cause injury or increase muscle strain. The clonic phase involves rhythmic jerking, and restraint may lead to fractures or soft tissue damage. Protecting the client by cushioning the head and ensuring safety is the priority.

Choice B reason: Placing a client on a BiPAP machine during a seizure is impractical and unsafe. The clonic phase involves uncontrolled movements, making BiPAP application impossible. Post-seizure, oxygenation may be needed, but during the seizure, protecting the client from injury, like head trauma, takes precedence.

Choice C reason: Placing a pillow under the client’s head during a tonic-clonic seizure protects against head injury from repetitive clonic movements against the floor. This action ensures safety by cushioning the head, reducing the risk of trauma or skull fracture, which is a priority during active seizure activity.

Choice D reason: Inserting a padded tongue blade is contraindicated during a seizure, as it risks injury to the mouth or airway obstruction. The jaw is often clenched in the clonic phase, and forcing objects into the mouth can cause dental damage or aspiration, making this an unsafe intervention.

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Correct Answer is A

Explanation

Choice A reason: A severe headache, vomiting, seizure, unresponsiveness, and vital signs showing hypertension (205/110 mm Hg), bradycardia (pulse 52/min), and irregular breathing suggest a hemorrhagic stroke. These indicate Cushing’s triad from increased intracranial pressure due to intracranial bleeding, causing brainstem compression and neurological deterioration, requiring urgent intervention.

Choice B reason: Transient ischemic attack (TIA) involves temporary neurological deficits without permanent damage, resolving within hours. Severe headache, seizure, unresponsiveness, and Cushing’s triad (hypertension, bradycardia) are inconsistent with TIA. These symptoms point to a more severe event, like hemorrhagic stroke, with significant intracranial pressure elevation.

Choice C reason: Embolic stroke, caused by a clot blocking a cerebral artery, typically presents with focal deficits like hemiparesis, not severe headache, seizure, or unresponsiveness with Cushing’s triad. These symptoms suggest a hemorrhagic stroke, where bleeding causes rapid intracranial pressure increase, leading to brainstem compression and autonomic changes.

Choice D reason: Thrombotic stroke involves gradual clot formation in a cerebral artery, causing focal neurological deficits like weakness or speech issues. Severe headache, seizure, unresponsiveness, and Cushing’s triad (hypertension, bradycardia) are more indicative of hemorrhagic stroke, where bleeding rapidly elevates intracranial pressure, leading to life-threatening neurological compromise.

A. Thrombolytic administration within 10 hrs B. Complete neurologic assessment every 12 hrs C. Alteplase administration within 4.5 hrs D. Vancomycin administration after blood culture

Correct Answer is C

Explanation

Choice A reason: Thrombolytic administration within 10 hours is incorrect, as the therapeutic window for thrombolytics like alteplase in ischemic stroke is typically 3–4.5 hours from symptom onset. Beyond this, the risk of hemorrhage outweighs benefits, making timely administration critical to restore cerebral blood flow and minimize brain damage.

Choice B reason: Completing neurologic assessments every 12 hours is important for monitoring but is not the next action post-CT confirming ischemic stroke. Urgent thrombolytic therapy (e.g., alteplase) within 4.5 hours takes priority to dissolve the clot, restore perfusion, and limit infarct size, improving neurological outcomes.

Choice C reason: Alteplase administration within 4.5 hours is the next step post-CT confirming ischemic stroke. This thrombolytic dissolves the clot obstructing cerebral blood flow, minimizing brain tissue damage. The narrow time window ensures efficacy and reduces hemorrhage risk, making it the priority intervention to improve stroke outcomes.

Choice D reason: Vancomycin administration after blood culture is irrelevant for ischemic stroke, which results from a clot, not infection. Antibiotics like vancomycin treat bacterial infections, not cerebral ischemia. The priority is thrombolytic therapy like alteplase to restore blood flow and prevent further brain tissue damage.

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A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The stroke team and primary nurse received CT scan results of their client experiencing an ischemic stroke. Which of the following interventions will the team do next?

Correct Answer is C

Explanation

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