A patient is being evaluated for a possible spinal cord tumor. Which finding should the nurse recognize as requiring the most immediate action?

A. The patient reports chronic severe back pain: Chronic severe back pain may indicate underlying spinal issues but does not necessarily require immediate action compared to acute symptoms such as new-onset weakness of both legs.

B. The patient expresses anxiety about having surgery: While addressing the patient's anxiety is important for providing holistic care, it is not the most immediate concern compared to new- onset weakness of both legs, which may indicate spinal cord compression requiring urgent
intervention.

C. The patient has new-onset weakness of both legs: New-onset weakness of both legs suggests potential spinal cord compression or neurological deficit requiring immediate evaluation and intervention to prevent further neurological damage or complications.

D. The patient starts to cry and says, "I feel hopeless": While addressing the patient's emotional needs is important, it is not the most immediate concern compared to addressing acute neurological symptoms such as new-onset weakness of both legs.

A. Restrain the patient's arms and legs to prevent injury during the seizure: Restraint during a seizure can potentially cause harm to the patient and should be avoided. It is essential to ensure the patient's safety by protecting the head and providing a safe environment.

B. Time and observe and record the details of the seizure and postictal state: Timing the seizure, observing the type and duration of movements, and noting any changes in the patient's behavior during the postictal state are crucial for documenting the seizure accurately and guiding further management.

C. Insert an oral airway during the seizure to maintain a patent airway: Inserting an oral airway during an active seizure is not recommended and can increase the risk of injury to the patient's airway. Maintaining a clear airway is important, but interventions such as positioning and
suctioning may be sufficient without the need for airway adjuncts during the seizure.

D. Avoid touching the patient to prevent further nervous system stimulation: While it's essential to minimize stimulation during a seizure, avoiding touching the patient altogether may not be feasible or necessary for providing care. Ensuring a safe environment and providing appropriate support are priorities during a seizure.