A patient is admitted to the Emergency Department (ED). The nurse documents "postictal upon transfer" as evidenced by which observation?

Abnormal sensory sensations including tingling of the skin

Yellowing of the skin

Severe itching of the eyes

Is in a drowsy confused state after a seizure

Answer and Explanation

The Correct Answer is D

A. Abnormal sensory sensations such as tingling may be associated with the aura phase of a seizure but are not typically observed postictally.

B. Yellowing of the skin is usually indicative of jaundice, unrelated to seizure activity or the postictal state.

C. Itching of the eyes is unrelated to seizure activity and would not typically be documented in the context of postictal observations.

D. The postictal state is characterized by drowsiness, confusion, and other altered mental statuses that follow a seizure. This period can vary in duration depending on the patient and seizure type.

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Correct Answer is B

Explanation

A. Removing objects is contraindicated, as it can worsen the injury.

B. Stabilizing the object and covering it prevents further injury until medical evaluation, which is critical in cases of eye trauma. Moving or removing a foreign body could lead to additional damage.

C. Providing a light meal is not directly related to managing eye trauma and does not address the immediate concern.

D. Blowing the nose could increase intraocular pressure, potentially worsening the injury.

A. Use the head tilt chin lift method to maintain the airway B. Control any external bleeding C. Do not move the victim from the accident D. Stabilize the cervical spine until help arrives

Correct Answer is D

Explanation

A. The head tilt chin lift method should be avoided due to the risk of aggravating a spinal injury; the jaw-thrust maneuver is safer if airway management is necessary.

B. While controlling bleeding is important, cervical spine stabilization takes priority in trauma with suspected spinal injury.

C. Not moving the victim is appropriate, but stabilizing the cervical spine provides active support to avoid further injury.

D. Stabilizing the cervical spine is crucial to prevent potential spinal cord damage in an unconscious trauma victim, particularly in a motor vehicle accident. This action helps prevent exacerbation of any spinal injury.

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A patient is admitted to the Emergency Department (ED). The nurse documents "postictal upon transfer" as evidenced by which observation?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who has sustained eye trauma as a result of a motor vehicle crash (MVC). Which intervention should the nurse provide regarding a foreign body?

Correct Answer is B

Explanation

The nurse is the first person on the scene of a motor vehicle crash. The victim was the driver and is in the driver's seat unconscious. The driver is breathing, has a pulse, and has minor lacerations on the head and face. What action should the nurse implement first?

Correct Answer is D

Explanation

The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

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