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Epilepsy: Status epilepticus
Epilepsy: Status epilepticus ( 4 Questions)
This is an incorrect answer. Administering IV lorazepam as prescribed is an important action for the nurse to take for a client who has epilepsy and is experiencing status epilepticus, but it is not the first action. Lorazepam is a benzodiazepine that can stop or reduce seizure activity by enhancing the inhibitory effects of gamma-aminobutyric acid (GABA) in the brain. However, before administering any medication, the nurse should ensure that the client's airway and head are protected from injury or obstruction.
This is a correct answer. Protecting the client's airway and head is the first action that the nurse should take for a client who has epilepsy and is experiencing status epilepticus. Status epilepticus is a medical emergency that occurs when a seizure lasts longer than 5 minutes or when two or more seizures occur without recovery of consciousness in between. Status epilepticus can cause hypoxia, brain damage, or death if not treated promptly. The nurse should protect the client's airway and head by placing them in a side-lying position, removing any objects or clothing that may restrict breathing, inserting an oral airway if needed, and padding the side rails or bed to prevent injury.
This is an incorrect answer. Monitoring the client's vital signs and oxygen saturation is an important action for the nurse to take for a client who has epilepsy and is experiencing status epilepticus, but it is not the first action. Vital signs and oxygen saturation can indicate the severity and effects of seizure activity on the client's cardiovascular, respiratory, and neurological systems. The nurse should monitor these parameters closely and provide oxygen therapy if needed to maintain adequate oxygenation and perfusion of the brain. However, before monitoring any parameters, the nurse should ensure that the client's airway and head are protected from injury or obstruction.
This is an incorrect answer. Documenting the onset, duration, and characteristics of the seizure is an important action for the nurse to take for a client who has epilepsy and is experiencing status epilepticus, but it is not the first action. Documentation can provide valuable information for diagnosis, treatment, and evaluation of seizure activity and its effects on the client's condition and quality of life. The nurse should document these details accurately and objectively as soon as possible after the seizure ends. However, before documenting any details, the nurse should ensure that the client's airway and head are protected from injury or obstruction.
Choice A reason:
This is an incorrect answer. Administering IV lorazepam as prescribed is an important action for the nurse to take for a client who has epilepsy and is experiencing status epilepticus, but it is not the first action. Lorazepam is a benzodiazepine that can stop or reduce seizure activity by enhancing the inhibitory effects of gamma-aminobutyric acid (GABA) in the brain. However, before administering any medication, the nurse should ensure that the client's airway and head are protected from injury or obstruction.
Choice B reason:
This is a correct answer. Protecting the client's airway and head is the first action that the nurse should take for a client who has epilepsy and is experiencing status epilepticus. Status epilepticus is a medical emergency that occurs when a seizure lasts longer than 5 minutes or when two or more seizures occur without recovery of consciousness in between. Status epilepticus can cause hypoxia, brain damage, or death if not treated promptly. The nurse should protect the client's airway and head by placing them in a side-lying position, removing any objects or clothing that may restrict breathing, inserting an oral airway if needed, and padding the side rails or bed to prevent injury.
Choice C reason:
This is an incorrect answer. Monitoring the client's vital signs and oxygen saturation is an important action for the nurse to take for a client who has epilepsy and is experiencing status epilepticus, but it is not the first action. Vital signs and oxygen saturation can indicate the severity and effects of seizure activity on the client's cardiovascular, respiratory, and neurological systems. The nurse should monitor these parameters closely and provide oxygen therapy if needed to maintain adequate oxygenation and perfusion of the brain. However, before monitoring any parameters, the nurse should ensure that the client's airway and head are protected from injury or obstruction.
Choice D reason:
This is an incorrect answer. Documenting the onset, duration, and characteristics of the seizure is an important action for the nurse to take for a client who has epilepsy and is experiencing status epilepticus, but it is not the first action. Documentation can provide valuable information for diagnosis, treatment, and evaluation of seizure activity and its effects on the client's condition and quality of life. The nurse should document these details accurately and objectively as soon as possible after the seizure ends. However, before documenting any details, the nurse should ensure that the client's airway and head are protected from injury or obstruction.