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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 C

Explanation

A. Reorienting confused patients is important but is not directly related to cerebellar injury.

B. While turning every 2 hours is important to prevent pressure injuries, it does not address the specific fall risk associated with cerebellar damage.

C. The cerebellum is responsible for balance and coordination, so injuries in this area increase the risk of falls. Ensuring the bed alarm is on provides immediate alerts if the patient attempts to get out of bed, helping to prevent falls.

D. Varying the schedule to prevent boredom is not a priority in the care of patients with cerebellar injury.

A. "Use a cane or walker when you begin to have difficulty walking." B. "Adjust the dose depending upon observed seizure activity." C. "You will need to have blood levels drawn annually." D. "Be sure to have regular visits to the dentist."

Correct Answer is D

Explanation

A. While using a cane or walker may be necessary for some patients experiencing balance issues, it is not a specific instruction related to phenytoin.

B. Phenytoin dosages should not be adjusted solely based on observed seizure activity; the dose must be managed carefully based on serum drug levels and the clinician's guidance.

C. Patients on phenytoin typically require more frequent monitoring of blood levels (every 2-3 months initially) rather than annually, as maintaining therapeutic levels is essential to avoid toxicity or ineffective seizure control.

D. Regular dental visits are crucial for patients taking phenytoin because the medication can cause gingival hyperplasia (overgrowth of gum tissue), which necessitates careful dental hygiene and regular monitoring by a dentist to prevent complications.

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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 diagnosed with a brain injury to the cerebellum. Which nursing intervention is priority?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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