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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Decreased hematocrit and hemoglobin indicate anemia, which is a condition where the blood does not carry enough oxygen to the tissues. This can cause symptoms such as confusion, restlessness, fatigue, and weakness in older adults.
Choice B reason: Increased erythrocyte count, or polycythemia, is a condition where the blood has too many red blood cells. This can cause the blood to become thick and viscous, which can impair blood flow and oxygen delivery. However, this is not the best explanation for the patient's confusion and restlessness, as polycythemia usually causes symptoms such as headache, dizziness, itching, and flushing.
Choice C reason: Normochromic red blood cells are red blood cells that have a normal color and hemoglobin content. This is not a finding that would explain the patient's confusion and restlessness, as it indicates a normal red blood cell function.
Choice D reason: Decreased thrombocytes, or platelets, are blood cells that help with clotting. This is a finding that would increase the risk of bleeding, but not the risk of confusion and restlessness. Decreased thrombocytes can cause symptoms such as bruising, bleeding gums, nosebleeds, and petechiae.
Correct Answer is A
Explanation
Choice A reason: The hypoglossal nerve is responsible for the movement of the tongue. It innervates the muscles of the tongue and allows for speech, swallowing, and chewing.
Choice B reason: The trigeminal nerve is responsible for the sensation and motor function of the face. It innervates the muscles of mastication, the skin of the face, and the mucous membranes of the mouth and nose.
Choice C reason: The facial nerve is responsible for the expression and taste of the face. It innervates the muscles of facial expression, the lacrimal and salivary glands, and the anterior two-thirds of the tongue.
Choice D reason: The vestibulocochlear nerve is responsible for the hearing and balance of the ear. It innervates the cochlea and the vestibular apparatus of the inner ear.
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