A nurse is caring for a client experiencing a tonic-clonic seizure. What is the nursing priority in caring for this client?

Educating the client on anticonvulsant medications

Monitor vital signs

Restraining the client

Prevention of occlusion of airway or aspiration

Answer and Explanation

The Correct Answer is D

A. Educating the client on anticonvulsant medications is important, but it is not the priority during an active seizure. Education should be provided after the seizure has ended.

B. Monitoring vital signs is important but should not be the immediate priority during a seizure. The nurse should focus on airway management first.

C. Restraining the client is contraindicated during a seizure. Restraining can cause injury to both the client and the nurse. The focus should be on protecting the client from harm.

D. The prevention of occlusion of the airway or aspiration is the priority. During a tonic-clonic seizure, there is a risk of the client choking, biting their tongue, or having difficulty breathing. The nurse should ensure the airway is open, prevent aspiration, and protect the client from injury during the seizure.

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Correct Answer is B

Explanation

A. Unstable blood pressure can occur with damage to the hypothalamus or pituitary, but it is more commonly associated with other neurological conditions. While blood pressure may fluctuate, it is not the most direct result of pituitary or hypothalamic damage.

B. Diabetes insipidus is the correct answer. The pituitary gland secretes antidiuretic hormone (ADH), which helps regulate water balance. Damage to the pituitary or hypothalamus can lead to a deficiency of ADH, causing diabetes insipidus, which is characterized by excessive thirst and urination.

C. Diabetes mellitus is a condition related to insulin production and blood sugar regulation, typically caused by pancreatic issues, not damage to the pituitary or hypothalamus.

D. Altered respiratory rate can occur with brain injury, but it is more commonly associated with damage to the brainstem rather than the hypothalamus or pituitary.

A. Palpebral angle rigid, right and left angles B. Patient's eyes round, regular, lively, active C. Pupils equal, round, and reactive to light and accommodation D. Pupils equilateral, regular, round, little accommodation

Correct Answer is C

Explanation

A. Palpebral angle rigid, right and left angles is not a part of the PERRLA assessment. The term refers to the space between the eyelids, which is not assessed with the PERRLA acronym.

B. Patient's eyes round, regular, lively, active is a description of the general appearance of the eyes but does not correspond to the PERRLA acronym, which specifically addresses the pupils' response to light and accommodation.

C. PERRLA stands for Pupils Equal, Round, and Reactive to Light and Accommodation. This means the pupils should be equal in size, round in shape, react to light (constricting when exposed to light), and accommodate (adjust) when focusing on near or far objects. This is a standard neurological assessment used to evaluate the functioning of the eyes and the nervous system.

D. Pupils equilateral, regular, round, little accommodation does not accurately describe PERRLA. The correct term is "accommodation," which refers to the pupils' ability to adjust when focusing on near or far objects, not "little accommodation."

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A nurse is caring for a client experiencing a tonic-clonic seizure. What is the nursing priority in caring for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A traumatic brain injury that affects the pituitary gland or hypothalamus can cause which of the following?

Correct Answer is B

Explanation

The nurse performs a visual assessment on a patient and documents the findings using the acronym PERRLA. Which assessment finding does PERRLA indicate?

Correct Answer is C

Explanation

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