Nokea
A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?
- A. Restrain the patient to prevent injury.
- B. Open the patients jaws to insert an oral airway.
- C. Place patient in high Fowlers position.
- D. Loosen the patients restrictive clothing
Correct Answer: D
Rationale: Loosening restrictive clothing prevents injury during a seizure. Restraining or inserting an airway can cause harm, and high Fowlers is inappropriate during a seizure.
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The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the patient has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following?
- A. The ability of the patient to follow instructions during the seizure.
- B. The success or failure of the care team to physically restrain the patient.
- C. The patients ability to explain his seizure during the postictal period.
- D. The patients activities immediately prior to the seizure.
Correct Answer: D
Rationale: Documenting pre-seizure activities helps identify triggers. Patients cannot follow instructions or explain seizures during or postictally, and restraint is contraindicated.
A patient has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication?
- A. Vigilant monitoring of fluid balance
- B. Continuous BP monitoring
- C. Serial arterial blood gases (ABGs)
- D. Monitoring of the patients airway for patency
Correct Answer: A
Rationale: Diabetes insipidus causes extreme polyuria, requiring close fluid balance monitoring. BP, ABGs, and airway monitoring are less directly related.
The nurse is caring for a patient whose recent health history includes an altered LOC. What should be the nurses first action when assessing this patient?
- A. Assessing the patients verbal response
- B. Assessing the patients ability to follow complex commands
- C. Assessing the patients judgment
- D. Assessing the patients response to pain
Correct Answer: A
Rationale: Verbal response assessment, via orientation to time, person, and place, is the initial step in evaluating altered LOC. Other assessments follow based on findings.
The nurse is participating in the care of a patient with increased ICP. What diagnostic test is contraindicated in this patients treatment?
- A. Computed tomography (CT) scan
- B. Lumbar puncture
- C. Magnetic resonance imaging (MRI)
- D. Venous Doppler studies
Correct Answer: B
Rationale: Lumbar puncture risks brain herniation in patients with increased ICP due to pressure changes. CT, MRI, and Doppler studies are safe and non-invasive.
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patients plan of care?
- A. Monitoring of pulse oximetry
- B. Administration of a low-protein diet
- C. Administration of thorough oral hygiene
- D. Fluid restriction as ordered
Correct Answer: C
Rationale: Phenytoin can cause gingival hyperplasia, making thorough oral hygiene essential. Pulse oximetry, low-protein diet, and fluid restriction are not related to phenytoin's adverse effects.