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The nurse is performing the morning assessment on a patient. The patient suddenly screams loudly and begins to have a generalized tonic/clonic type seizure. What is the priority nursing intervention?

Place soft restraints on the patient

Place a padded tongue blade in the client's mouth

Turn the patient on the side and stay with them

Immediately go to the nurses' station for help

Respirations

Answer and Explanation

The Correct Answer is C

A. Soft restraints are not recommended during a seizure and can cause harm to the patient.

B. Placing anything in the mouth during a seizure can lead to injury or airway obstruction and is contraindicated.

C. Turning the patient on their side helps to maintain an open airway and prevent aspiration; staying with the patient ensures ongoing monitoring.

D. Leaving the patient alone to seek help is unsafe, as it leaves the patient unmonitored during the seizure.

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Correct Answer is B

Explanation

A. While taking some medications with food or milk can help with absorption, this is not a specific requirement for lisinopril.

B. Lisinopril, an ACE inhibitor, can lead to elevated potassium levels. Periodic monitoring of potassium levels is essential to prevent hyperkalemia, a potentially dangerous side effect.

C. Increasing intake of green vegetables is generally healthy but does not directly impact lisinopril's effects.

D. Many salt substitutes contain potassium, which could elevate potassium levels further when taken with ACE inhibitors like lisinopril, posing a risk for hyperkalemia.

A. accident injured the patient's lungs. B. patient has a history of smoking. C. nerves that control the lung function have been injured. D. patient is unable to breathe because he is unconscious.

Correct Answer is C

Explanation

A. While lung injury could occur in traumatic situations, it is not the primary reason for mechanical ventilation in the context of a spinal cord injury.

B. A history of smoking may affect lung health but does not directly justify the immediate need for mechanical ventilation following a spinal cord injury.

C. The nerves that control lung function may be injured in a cervical spinal cord injury, particularly at higher levels like C3-C5, leading to respiratory muscle paralysis and necessitating mechanical ventilation to support breathing.

D. While unconsciousness may complicate breathing, the primary concern is the loss of function in the spinal cord nerves controlling respiration.

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The nurse is performing the morning assessment on a patient. The patient suddenly screams loudly and begins to have a generalized tonic/clonic type seizure. What is the priority nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who will be discharged with a prescription for lisinopril. What discharge teaching should be provided related to this medication?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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