An adult client who has been experiencing a seizure for approximately 15 minutes is brought to the emergency department by private vehicle. Which intervention should the nurse implement first?
Administer levetiracetam intravenously.
Obtain a STAT electroencephalogram.
Administer lorazepam intravenously.
Obtain a STAT 12-lead electrocardiogram.
The Correct Answer is C
Choice A Reason:
Administering levetiracetam intravenously is not the first intervention. While levetiracetam is an antiepileptic drug used to control seizures, it is not the first-line treatment for an ongoing seizure, especially one lasting as long as 15 minutes. The priority in this situation is to stop the seizure activity immediately to prevent further complications, such as neuronal damage or status epilepticus. Levetiracetam may be used later for maintenance therapy, but it is not the initial emergency intervention.
Choice B Reason:
Obtaining a STAT electroencephalogram (EEG) is important for diagnosing and understanding the type of seizure activity, but it is not the first intervention. The immediate priority is to stop the seizure. An EEG can be performed after the seizure has been controlled to assess brain activity and guide further treatment. Delaying the administration of an anticonvulsant to perform an EEG could result in prolonged seizure activity and increased risk of complications.
Choice C Reason:
Administering lorazepam intravenously is the most appropriate first intervention. Lorazepam is a benzodiazepine that acts quickly to stop seizure activity. It is the drug of choice for treating status epilepticus and prolonged seizures because of its rapid onset and effectiveness. Administering lorazepam helps to quickly terminate the seizure, reducing the risk of complications and stabilizing the patient for further evaluation and treatment.
Choice D Reason:
Obtaining a STAT 12-lead electrocardiogram (ECG) is not the first intervention. While an ECG can provide valuable information about the patient’s cardiac status, it does not address the immediate need to stop the seizure. The priority is to administer an anticonvulsant to terminate the seizure. Once the seizure is controlled, an ECG can be performed to assess any potential cardiac issues, especially if the patient has a history of cardiac problems or if the seizure was triggered by a cardiac event.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Metabolic alkalosis is characterized by an elevated pH (greater than 7.45) and an increased bicarbonate (HCO3) level. In this case, the pH is 7.30, indicating acidosis, and the HCO3 level is 18 mEq/L, which is below the normal range (22-26 mEq/L). Therefore, metabolic alkalosis is not the correct diagnosis.
Choice B Reason:
Respiratory alkalosis is indicated by a high pH (greater than 7.45) and a low PaCO2 (less than 35 mm Hg). Although the PaCO2 is low at 28 mm Hg, the pH is 7.30, indicating acidosis rather than alkalosis. Therefore, respiratory alkalosis is not the correct diagnosis.
Choice C Reason:
Respiratory acidosis is characterized by a low pH (less than 7.35) and an elevated PaCO2 (greater than 45 mm Hg). In this case, the pH is low, indicating acidosis, but the PaCO2 is also low at 28 mm Hg, which does not fit the criteria for respiratory acidosis. Therefore, respiratory acidosis is not the correct diagnosis.
Choice D Reason:
Metabolic acidosis is indicated by a low pH (less than 7.35) and a low bicarbonate (HCO3) level (less than 22 mEq/L). In this case, the pH is 7.30, indicating acidosis, and the HCO3 level is 18 mEq/L, which is below the normal range. The low PaCO2 of 28 mm Hg suggests a compensatory respiratory response to the metabolic acidosis. Therefore, metabolic acidosis is the correct diagnosis.
Correct Answer is ["A","C","E"]
Explanation
Choice A Reason:
Weight loss.
Weight loss is a common symptom of hyperthyroidism. This condition speeds up the body’s metabolism, causing the body to burn calories more quickly than usual. Despite an increased appetite, individuals with hyperthyroidism often experience significant weight loss. This symptom is a direct result of the overproduction of thyroid hormones, which increases the metabolic rate.
Choice B Reason:
Intolerance to cold.
Intolerance to cold is not typically associated with hyperthyroidism; it is more commonly a symptom of hypothyroidism. Hyperthyroidism usually causes heat intolerance due to the increased metabolic rate, which raises the body’s temperature. Therefore, this choice is not relevant to hyperthyroidism.
Choice C Reason:
An elevated systolic blood pressure.
An elevated systolic blood pressure can be a symptom of hyperthyroidism. The increased levels of thyroid hormones can cause the heart to work harder, leading to higher blood pressure. This symptom is important to monitor as it can lead to further cardiovascular complications if left untreated.
Choice D Reason:
A heart rate of 90 bpm.
A heart rate of 90 bpm is within the normal range for adults and is not specifically indicative of hyperthyroidism. Hyperthyroidism typically causes a rapid or irregular heartbeat, often exceeding 100 bpm. Therefore, this choice does not accurately reflect a clinical manifestation of hyperthyroidism.
Choice E Reason:
Increased fatigability.
Increased fatigability is a common symptom of hyperthyroidism. Despite the increased metabolic rate, individuals with hyperthyroidism often feel tired and weak. This paradoxical symptom occurs because the body’s systems are overworked and cannot sustain the heightened activity levels, leading to fatigue.
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