Which prescribed intervention should the emergency department nurse implement first for a patient who is experiencing continuous tonic-clonic seizures?

Monitor level of consciousness (LOC)

Administer lorazepam (Ativan) 4 mg IV.

Obtain computed tomography (CT) scan.

Give phenytoin (Dilantin) 100 mg IV.

Answer and Explanation

The Correct Answer is B

A. Monitor level of consciousness (LOC): While monitoring the patient's level of consciousness is important, administering medication to stop the seizure takes precedence to prevent potential complications associated with prolonged seizure activity.

B. Administer lorazepam (Ativan) 4 mg IV: The priority in managing continuous tonic-clonic seizures is to terminate the seizure activity promptly. Lorazepam is a benzodiazepine that can help to abort seizures and is often used as first-line treatment in the acute setting.

C. Obtain computed tomography (CT) scan: While obtaining diagnostic imaging such as a CT scan may be necessary to evaluate for underlying causes of the seizure, it is not the first
intervention in the acute management of continuous seizures. Stabilizing the patient and stopping the seizure activity take precedence.

D. Give phenytoin (Dilantin) 100 mg IV: Phenytoin is an antiepileptic medication that is used for long-term management of seizures but is not typically administered as first-line treatment during an acute seizure episode. Benzodiazepines like lorazepam are preferred for immediate seizure control.

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Correct Answer is C

Explanation

A. Administer naproxen: While pain management is important, naproxen may not effectively resolve the headache associated with post-lumbar puncture headache (PLPH), which is often caused by cerebrospinal fluid leakage.

B. Elevate the head of the bed to 30°: While elevating the head of the bed may provide some relief, it is not typically sufficient to resolve PLPH, which often requires more definitive interventions.

C. Check BP and call for a blood patch: PLPH is commonly treated with a blood patch, which involves injecting the patient's own blood into the epidural space to seal the puncture site and restore normal cerebrospinal fluid pressure. Checking blood pressure is important to assess for hypotension, and calling for a blood patch is the most appropriate action to address the underlying cause of the headache.

D. Darken the client's room and close the door: While creating a quiet and dim environment may help alleviate symptoms of headache, it does not address the underlying cause of PLPH and is not the most appropriate intervention in this situation.

A. Suction Tubing B. Nasogastric Tube C. Urinary Catheter D. Tongue Blade E. Oxygen Mask F. Side Rail Pad

Correct Answer is ["A","E","F"]

Explanation

A. Suction Tubing: This equipment is necessary for clearing the patient's airway in case of any secretions or vomitus that could obstruct breathing following a seizure episode.

B. Nasogastric Tube: While nasogastric tubes may be necessary in some medical conditions, they are not typically indicated following treatment for status epilepticus unless there are specific concerns related to the patient's condition that require gastric decompression or feeding.

C. Urinary Catheter: While urinary catheters may be used in some cases, they are not routinely required following treatment for status epilepticus unless there are specific concerns about urinary retention or monitoring of urine output.

D. Tongue Blade: Tongue blades are not typically necessary following treatment for status epilepticus. They may pose a risk of injury to the patient if used unnecessarily.

E. Oxygen Mask: Oxygen masks are essential for providing supplemental oxygen to the patient, especially if there are concerns about hypoxia following a seizure episode.

F. Side Rail Pad: Side rail pads are important for preventing injury to the patient during postictal confusion or agitation. They help to protect the patient from accidentally falling out of bed or injuring themselves against the bed rails.

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Which prescribed intervention should the emergency department nurse implement first for a patient who is experiencing continuous tonic-clonic seizures?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports a throbbing headache and hypotension after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

Correct Answer is C

Explanation

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room? (Select all that apply.)

Correct Answer is ["A","E","F"]

Explanation

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