A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

Choice A reason: This is the correct answer. Administering diazepam via intravenous push is the first-line treatment for status epilepticus to quickly control and terminate the seizure activity. Rapid intervention is crucial to prevent prolonged seizures and potential complications.

Choice B reason: Preparing to administer a glucocorticoid orally is not the immediate first step in managing status epilepticus. Glucocorticoids may be used in specific cases, but the priority is to stop the seizure with fast-acting medications like diazepam.

Choice C reason: Monitoring the client's cardiac rhythm via telemetry is important, especially given the potential cardiovascular effects of seizures and medications. However, it is not the immediate first action. Controlling the seizure takes precedence.

Choice D reason: Assessing the client's neurological status every hour is part of ongoing care, but it is not the first intervention. The immediate goal is to terminate the seizure activity to prevent further neurological damage.

Choice A reason:

Monitoring the Glasgow Coma Scale (GCS) is used to assess a client's level of consciousness, typically in cases of head injury or altered mental status. It is not relevant to the assessment of a pressure injury, which requires evaluating the risk factors and extent of skin damage.

Choice B reason:

Completing the Braden Scale is the appropriate action for assessing a client with a pressure injury. The Braden Scale evaluates risk factors for pressure ulcers, including sensory perception, moisture, activity, mobility, nutrition, and friction/shear. This tool helps in creating an effective care plan to prevent further skin breakdown and manage existing ulcers.

Choice C reason:

Initiating a Brudzinski flow sheet pertains to neurological assessment, specifically testing for signs of meningitis. It is not relevant to the assessment or management of pressure injuries in a paraplegic client.

Choice D reason:

Assessing for Babinski's sign is a neurological test to evaluate corticospinal tract function. While important in a complete neurological examination, it does not address the specific needs related to pressure injury assessment and management.