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 C

Explanation

A. While drug dependence can be a concern with long-term use, it is not the immediate priority in an emergency setting where the goal is to stabilize the patient in status epilepticus.

B. Cardiac rhythm monitoring is important when administering certain medications, but lorazepam primarily affects the central nervous system and respiratory system, making oxygen saturation monitoring more critical.

C. Pulse oximetry is the priority assessment as IV lorazepam can depress the respiratory system, leading to hypoxia. Monitoring oxygen saturation helps ensure the patient maintains adequate respiratory function during administration.

D. Assessing pain is important in patient care, but it is not the priority in managing a patient in status epilepticus, where stabilization is essential.

A. Altered mental status B. Tachycardia and hypotension C. Fixed and dilated pupils D. Widening pulse pressure

Correct Answer is A

Explanation

A. Altered mental status, such as confusion, restlessness, or lethargy, is often the earliest sign of increasing ICP as it reflects brain tissue compression.

B. Tachycardia and hypotension are not primary indicators of elevated ICP.

C. Fixed and dilated pupils indicate severe and often irreversible ICP increase, occurring later in the progression.

D. Widening pulse pressure is a later sign of increased ICP, following changes in mental status.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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