The nurse is at bedside with a client who started having a tonic-clonic seizure. Which of the following actions should the nurse implement first during the ictal stage?
Turn the client on their side
Administer 1 mg of IV lorazepam
Administer oxygen via a nonrebreather mask
Assess the client’s level of consciousness
The Correct Answer is A
Choice A reason: Turning the client on their side during a tonic-clonic seizure ensures airway patency by preventing aspiration of secretions. This is the first priority for safety, making it the correct action.
Choice B reason: Administering lorazepam stops seizures but is secondary to ensuring a clear airway. Safety during the ictal phase prioritizes positioning, making this incorrect as the first action.
Choice C reason: Oxygen administration is supportive but not the first action. Maintaining an open airway by positioning prevents aspiration, making this incorrect compared to turning the client.
Choice D reason: Assessing consciousness is irrelevant during the active seizure phase. Protecting the airway through positioning is the priority, making this incorrect as the first intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Hypotension is not a sign of increased ICP; hypertension is part of Cushing’s triad. Low blood pressure may indicate shock, not ICP, making this incorrect for monitoring brain injury.
Choice B reason: Decreased level of consciousness is a primary sign of increased ICP, reflecting brain compression. It’s a critical indicator requiring immediate action, making this the correct manifestation to monitor.
Choice C reason: Tachypnea is not typical of ICP; irregular or slow respirations occur in Cushing’s triad. Rapid breathing is unrelated, making this incorrect for increased ICP manifestations.
Choice D reason: Bilateral weakness may occur in neurological conditions but is less specific to ICP than altered consciousness. ICP primarily affects alertness, making this incorrect for monitoring.
Correct Answer is D
Explanation
Choice A reason: Osmotic diuretics like mannitol remove fluid, not hydrate. They draw water from tissues, reducing brain edema, so providing hydration is the opposite effect, making this incorrect.
Choice B reason: Expanding extracellular fluid volume would worsen edema. Osmotic diuretics reduce fluid in tissues, decreasing ICP, making this incorrect for the medication’s purpose in this scenario.
Choice C reason: Increasing brain cell size would exacerbate ICP. Osmotic diuretics shrink cells by drawing out water, reducing edema, making this incorrect for the medication’s intended effect.
Choice D reason: Osmotic diuretics reduce brain edema by drawing water from tissues into
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