The nurse should complete which essential interventions for a patient who has experienced status epilepticus?

Administer a dose of a prescribed antiepileptic drug and position the person supine.

Wrap the patient in warm blankets and hyperextend their neck.

Offer the patient a crossword to work on to promote mental stimulation.

Establish that the patient has a patent airway after the seizure ends and assess for breathing.

Answer and Explanation

The Correct Answer is D

Choice A reason: This is incorrect. Administering a dose of a prescribed antiepileptic drug is an appropriate intervention, but it should be done during the seizure, not after. Positioning the person supine is also not recommended, as it can compromise the airway and increase the risk of aspiration.

Choice B reason: This is incorrect. Wrapping the patient in warm blankets and hyperextending their neck are both harmful actions, as they can increase the body temperature and obstruct the airway. The patient should be kept cool and comfortable, and their head should be tilted to the side or supported with a pillow.

Choice C reason: This is incorrect. Offering the patient a crossword to work on to promote mental stimulation is not an essential intervention, and it may not be feasible or appropriate for a patient who has just experienced a prolonged seizure. The patient may need rest and observation, not cognitive tasks.

Choice D reason: This is correct. Establishing that the patient has a patent airway after the seizure ends and assessing for breathing are the most important interventions, as they ensure the oxygenation and ventilation of the patient. The nurse should also monitor the vital signs, neurological status, and blood glucose levels of the patient.

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Correct Answer is D

Explanation

Choice A reason: Assessment of arms and legs movement is an important part of the neurological assessment, but it is not the critical focus of care for a patient with a spinal cord injury at the cervical 5 vertebra. This level of injury affects the phrenic nerve, which controls the diaphragm and breathing. The patient may have difficulty breathing or require mechanical ventilation.

Choice B reason: Evaluation of knee jerk reflex is not the critical focus of care for a patient with a spinal cord injury at the cervical 5 vertebra. The knee jerk reflex is controlled by the spinal cord segments L2-L4, which are below the level of injury. The patient may have normal or exaggerated reflexes, depending on the extent of the spinal cord damage.

Choice C reason: Measurement of vital signs is a routine part of the nursing care, but it is not the critical focus of care for a patient with a spinal cord injury at the cervical 5 vertebra. The patient may have abnormal vital signs due to the injury, such as low blood pressure, slow heart rate, or irregular temperature. However, these are not as life-threatening as respiratory failure.

Choice D reason: Evaluation of respiratory status is the critical focus of care for a patient with a spinal cord injury at the cervical 5 vertebra. The patient is at high risk of respiratory compromise due to the impairment of the phrenic nerve and the diaphragm. The nurse should monitor the patient's oxygen saturation, respiratory rate, depth, and rhythm, and provide oxygen therapy or mechanical ventilation as needed. The nurse should also assess the patient for signs of respiratory infection, such as fever, cough, or sputum.

A. macrocytic, normochromic B. microcytic, hypochromic C. normocytic, normochromic D. microcytic, normochromic

Correct Answer is A

Explanation

Choice A reason: This is correct. Folic acid deficiency causes macrocytic, normochromic anemia, which means that the red blood cells are larger than normal, but have normal color and hemoglobin content. Folic acid is a vitamin that is needed for the synthesis of DNA and the maturation of red blood cells.

Choice B reason: This is incorrect. Microcytic, hypochromic anemia means that the red blood cells are smaller than normal and have less color and hemoglobin content. This type of anemia is caused by iron deficiency, not folic acid deficiency.

Choice C reason: This is incorrect. Normocytic, normochromic anemia means that the red blood cells are normal in size, color, and hemoglobin content, but there are fewer of them. This type of anemia is caused by blood loss, hemolysis, or bone marrow failure, not folic acid deficiency.

Choice D reason: This is incorrect. Microcytic, normochromic anemia means that the red blood cells are smaller than normal, but have normal color and hemoglobin content. This type of anemia is rare and is caused by disorders of red blood cell production, such as thalassemia or sideroblastic anemia, not folic acid deficiency.

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The nurse should complete which essential interventions for a patient who has experienced status epilepticus?

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