The nurse sees a visitor walking in the hallway begin to have a seizure. The nurse should do which of the following in priority order?
A. Maintain a patent airway.
B. Record the seizure activity observed.
C. Ease the visitor to the floor.
D. Obtain vital signs.
CABD
CADB
ACBD
ACDB
The Correct Answer is B
C. Ease the visitor to the floor: This is the first priority to prevent injury. Safely guiding the person to the ground helps reduce the risk of trauma from falling.
A. Maintain a patent airway: Once on the ground, the nurse should position the person (ideally on their side) to promote airway patency and prevent aspiration.
D. Obtain vital signs: After the seizure ends, assessing vital signs helps evaluate postictal status and detect any complications such as hypoxia or hypotension.
B. Record the seizure activity observed: Documentation of the seizure’s onset, duration, and characteristics is important, but it comes after safety and assessment priorities are addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cerebral embolism: Atrial fibrillation increases the risk of blood clots forming in the atria due to irregular blood flow. These clots can travel to the brain, causing a cerebral embolism. Clients with atrial fibrillation should be educated to monitor for symptoms like sudden weakness, confusion, difficulty speaking which are indicative of a stroke.
B. Bradycardia: While bradycardia (slow heart rate) may occur in some arrhythmias, atrial fibrillation is typically associated with an irregularly fast heart rate, not bradycardia. The primary concern in atrial fibrillation is the risk of stroke, not a slow heart rate.
C. Peripheral vascular disease: Peripheral vascular disease (PVD) is not directly related to atrial fibrillation. While PVD involves poor circulation in the limbs, it is not a common complication of atrial fibrillation. The main focus should be on preventing stroke.
D. Hypertension: Hypertension is a common condition associated with heart disease, but it is not the primary complication of atrial fibrillation. The most critical concern in atrial fibrillation is the increased risk of stroke due to clot formation in the heart.
Correct Answer is D
Explanation
A. Supraventricular Tachycardia (SVT): SVT is a rapid rhythm, typically 150-250 bpm, where P waves are often absent, abnormal, or hidden. The rate in this strip is 70 bpm, and clear P waves are present.
B. Sinus Bradycardia: Sinus bradycardia is characterized by a heart rate below 60 beats per minute. The heart rate in this strip is 70 bpm, which is not bradycardic.
C. Sinus Tachycardia: Sinus tachycardia is characterized by a heart rate greater than 100 beats per minute. The heart rate in this strip is 70 bpm, which is not tachycardic.
D. Normal Sinus Rhythm: The EKG strip demonstrates a regular rhythm with a heart rate between 60 and 100 beats per minute, and a normal P wave preceding every QRS complex, all consistent with the criteria for Normal Sinus Rhythm.
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