While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?

Restrain the patient's arms and legs to prevent injury during the seizure.

Time and observe and record the details of the seizure and postictal state.

Insert an oral airway during the seizure to maintain a patent airway.

Avoid touching the patient to prevent further nervous system stimulation.

Answer and Explanation

The Correct Answer is B

A. Restrain the patient's arms and legs to prevent injury during the seizure: Restraint during a seizure can potentially cause harm to the patient and should be avoided. It is essential to ensure the patient's safety by protecting the head and providing a safe environment.

B. Time and observe and record the details of the seizure and postictal state: Timing the seizure, observing the type and duration of movements, and noting any changes in the patient's behavior during the postictal state are crucial for documenting the seizure accurately and guiding further management.

C. Insert an oral airway during the seizure to maintain a patent airway: Inserting an oral airway during an active seizure is not recommended and can increase the risk of injury to the patient's airway. Maintaining a clear airway is important, but interventions such as positioning and
suctioning may be sufficient without the need for airway adjuncts during the seizure.

D. Avoid touching the patient to prevent further nervous system stimulation: While it's essential to minimize stimulation during a seizure, avoiding touching the patient altogether may not be feasible or necessary for providing care. Ensuring a safe environment and providing appropriate support are priorities during a seizure.

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Correct Answer is B

Explanation

A. Send the patient for a computed tomography (CT) scan: While obtaining a CT scan is important for diagnosing potential causes of the patient's left-sided hemiparesis, assessing the patient's respiratory status takes precedence to ensure adequate oxygenation and ventilation.

B. Check the respiratory rate and effort: Assessing the patient's respiratory rate and effort is the first priority to identify any signs of respiratory distress or compromise. Adequate oxygenation and ventilation are essential for maintaining vital organ function.

C. Assess the Glasgow Coma Scale score: While assessing the Glasgow Coma Scale score is important for evaluating the patient's level of consciousness and neurological status, it is not the first action to take in a patient with potential respiratory compromise.

D. Take the patient's blood pressure: While obtaining the patient's blood pressure is important for assessing hemodynamic stability, it is not the first priority when the patient presents with left-sided hemiparesis and may be at risk for respiratory compromise.

A. Transfer the patient to radiology. B. Enforce NPO status for 4 hours. C. Help the patient to a lateral position. D. Administer a sedative medication.

Correct Answer is C

Explanation

A. Transfer the patient to radiology: Lumbar punctures are typically performed at the bedside in the patient's room or in a procedure room, not in radiology.
B. Enforce NPO status for 4 hours: NPO (nothing by mouth) status is not typically required before a lumbar puncture unless specifically ordered by the healthcare provider for a particular reason.
C. Help the patient to a lateral position: Before a lumbar puncture, the patient should be placed in a lateral recumbent position (usually on their side with knees flexed towards the chest) to facilitate the procedure and minimize the risk of complications such as post-dural puncture headache.
D. Administer a sedative medication: Sedative medications are not routinely administered before a lumbar puncture, as they can alter the patient's level of consciousness and interfere with neurological assessment during and after the procedure.

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While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

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