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 A

Explanation

A. Patient has slight elevations in liver function test results: Phenytoin is primarily metabolized by the liver, and elevated liver function tests may indicate impaired liver function, potentially affecting the metabolism and clearance of phenytoin. Consultation with the healthcare provider is warranted to assess the risk-benefit ratio of administering phenytoin in the presence of liver function abnormalities.

B. Patient's most recent blood pressure is 156/92 mm Hg: While hypertension is not a contraindication for phenytoin administration, it is important to monitor blood pressure, especially considering the potential cardiovascular side effects of the medication. However, elevated blood pressure alone does not typically warrant consultation before administering phenytoin.

C. Patient experiences an aura before seizures: Experiencing an aura before seizures is a common phenomenon in patients with epilepsy and does not necessarily contraindicate the use of phenytoin. In fact, phenytoin is commonly prescribed to prevent seizures, including those preceded by an aura.

D. Patient has tonic-clonic seizures: Phenytoin is indicated for the treatment and prevention of tonic-clonic seizures, among other seizure types. Therefore, the presence of tonic-clonic seizures would not typically warrant consultation before administering phenytoin.

A. Restlessness B. Amnesia C. Tachycardia D. Hypotension

Correct Answer is A

Explanation

A. Restlessness: Restlessness is a common early sign of increased intracranial pressure (ICP) in clients with traumatic brain injury. It can result from discomfort, confusion, or agitation due to pressure on the brain.

B. Amnesia: Amnesia, or memory loss, can occur with traumatic brain injury but is not specifically indicative of increased intracranial pressure.

C. Tachycardia: Tachycardia may occur in response to various factors such as pain, stress, or fever, but it is not a specific indicator of increased intracranial pressure.

D. Hypotension: Hypotension (low blood pressure) is not typically associated with increased intracranial pressure. In fact, hypertension (high blood pressure) may be a compensatory response to maintain cerebral perfusion pressure in the setting of elevated ICP.

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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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