The nurse is providing care for a patient in status epilepticus. What nursing intervention takes the highest priority?

Maintain a patent airway

Place an intravenous catheter (IV)

Administer diazepam, per order

Insert a nasogastric tube (NG)

Answer and Explanation

The Correct Answer is A

Choice A rationale
Maintaining a patent airway is the highest priority when providing care for a patient in status epilepticus. Status epilepticus is a medical emergency characterized by prolonged or recurrent seizures. It can lead to severe complications, including respiratory distress and hypoxia.
Therefore, ensuring a patent airway is crucial to prevent hypoxia and further brain damage. This involves positioning the patient to prevent aspiration, potentially suctioning the airway, and providing supplemental oxygen as needed.
Choice B rationale
While placing an intravenous catheter (IV) is an important intervention, it is not the highest priority. An IV allows for the administration of medications and fluids, which are necessary in the management of status epilepticus. However, it is secondary to maintaining a patent airway.
Choice C rationale
Administering diazepam or other antiepileptic drugs is a key intervention in managing status epilepticus. These medications help to stop the seizures. However, medication administration should only occur after a patent airway has been established.
Choice D rationale
Inserting a nasogastric tube (NG) may be necessary in some cases to protect the airway or for administering medications or nutrition. However, this is not the highest priority intervention. The first step in managing status epilepticus is always to ensure a patent airway.

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Correct Answer is A

Explanation

Choice A rationale
Donepezil hydrochloride is a medication used to treat dementia related to Alzheimer’s disease. It works by improving mental function, such as memory and the ability to think and reason.
However, it is important to note that donepezil does not cure Alzheimer’s disease. The condition will worsen over time, even in people who take donepezil.
Choice B rationale
Donepezil does not limit the physical effects of Alzheimer’s disease and other dementias. While it can improve cognitive function, it does not directly impact the physical symptoms associated with these conditions.
Choice C rationale
Donepezil does not remove the patient’s insight that they have Alzheimer’s disease. It is a medication that helps to improve cognitive function, but it does not alter a person’s awareness or understanding of their condition.

Choice D rationale
Donepezil does not cure Alzheimer’s disease in any patients, let alone a small minority. It is a treatment that can help manage symptoms and improve cognitive function, but it does not stop the progression of the disease.

A. Support the right arm with a sling or pillow to prevent shoulder dislocation. B. Anticipate the client will exhibit some degree of expressive or receptive aphasia. C. Place the wheelchair on the client’s left side when transferring him into a wheelchair. D. Provide close supervision because of the client’s impulsiveness and poor judgment.

Correct Answer is D

Explanation

Choice A rationale
Supporting the right arm with a sling or pillow can help prevent shoulder dislocation, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice B rationale
While it is true that a patient who has experienced a stroke in the right hemisphere of the brain may exhibit some degree of expressive or receptive aphasia, anticipating this does not directly ensure the patient’s safety.
Choice C rationale

Placing the wheelchair on the client’s left side when transferring him into a wheelchair is a good practice, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice D rationale
Patients who have experienced a stroke in the right hemisphere of the brain often exhibit impulsiveness and poor judgment. Therefore, providing close supervision can help ensure the patient’s safety.

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The nurse is providing care for a patient in status epilepticus. What nursing intervention takes the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing patient education to a patient with early-stage Alzheimer’s disease (AD) and their family. The patient has been prescribed donepezil hydrochloride. What should the nurse explain to the patient and family about this drug?

Correct Answer is A

Explanation

The nurse is caring for a client who experienced a stroke in the right hemisphere of the brain. What should the nurse do to ensure the safety of the patient?

Correct Answer is D

Explanation

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