A nurse is caring for a patient who has just experienced a tonic-clonic seizure. Which of the following actions should the nurse perform first after ensuring the patient's safety?

Document the seizure activity in the patient's medical record.

Check the patient's vital signs

Administer oral antiepileptic medication.

Place the patient in a side-lying position.

Answer and Explanation

The Correct Answer is D

A.   Documenting the seizure activity is important but should be done after addressing immediate needs.
B.   Checking the patient's vital signs is important but is secondary to positioning the patient safely to prevent aspiration.
C.   Administering oral antiepileptic medication is necessary but not the first action following a tonic- clonic seizure.
D.   Placing the patient in a side-lying position immediately after the seizure ensures that the airway remains open and reduces the risk of aspiration.

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Correct Answer is D

Explanation

A. Applying soft restraints during a seizure could increase the risk of injury and is not recommended.
B. Administering lorazepam is often necessary in seizures, but the priority during a seizure is ensuring the airway is open and the patient is in a safe position.
C. Obtaining a seizure history is important but should be done after managing the acute situation.
D. The priority during a seizure is to ensure the patient's airway is open and to position them on their side to prevent aspiration and facilitate breathing.

A. Erosion of the gastric mucosa on endoscopy B. Decreased serum amylase levels C. Presence of Helicobacter pylori antibodies in serum D. Hypersecretion of hydrochloric acid

Correct Answer is A

Explanation

A. Erosion of the gastric mucosa on endoscopy is the hallmark of acute gastritis. Chronic alcohol use can irritate and inflame the stomach lining, leading to mucosal erosion, which is commonly seen during endoscopy in patients with this condition.
B. Decreased serum amylase levels are not typically associated with acute gastritis. Amylase levels are more commonly elevated in cases of pancreatitis, not gastritis.
C. The presence of Helicobacter pylori antibodies in serum is more indicative of chronic gastritis or peptic ulcer disease rather than acute gastritis. H. pylori is a long-term cause of gastric inflammation.
D. Hypersecretion of hydrochloric acid is more commonly associated with conditions such as Zollinger- Ellison syndrome and is not a typical finding in acute gastritis caused by alcohol use.

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A nurse is caring for a patient who has just experienced a tonic-clonic seizure. Which of the following actions should the nurse perform first after ensuring the patient's safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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