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. 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.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

Intracranial hemorrhage: Given the client's history of falling out of bed, subsequent head injury, headache, seizure, and neurological deterioration (weakness on the right side of the body, dilated right pupil, confusion), there is a significant concern for intracranial hemorrhage. These symptoms suggest possible bleeding within the skull, which can rapidly escalate and become life-threatening.

Heart rate: The client's decreasing heart rate from 70/min at 1230 to 40/min at 1430 indicates bradycardia, which can be a critical sign of increased intracranial pressure (ICP) due to intracranial hemorrhage. Bradycardia is a late sign of increased ICP and indicates severe neurological compromise. In this context, the irregular heart rate and the associated neurological symptoms raise concerns for impending or ongoing intracranial hemorrhage.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

A nurse is caring for a client on a medical-surgical unit. Exhibits Complete the following sentence by using the lists of options. The client is at highest risk for developing dropdown as evidenced by the client's dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

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