Nokea
The nurse is preparing to admit a patient who has been treated for status epilepticus in the emergency department. Which of the following equipment should the nurse have available in the room? (Select all that apply.)
- A. Side rail pads
- B. Tongue blade
- C. Oxygen mask
- D. Suction tubing
- E. Nasogastric tube
Correct Answer: A,C,D
Rationale: The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. Use of tongue blades during a seizure is contraindicated.
You may also like to solve these questions
The nurse is obtaining a health history and physical assessment from a patient with possible multiple sclerosis (MS). Which of the following assessment should the nurse include?
- A. Assess for the presence of chest pain.
- B. Inquire about any urinary tract problems.
- C. Inspect the skin for rashes or discoloration.
- D. Question the patient about any increase in libido.
Correct Answer: B
Rationale: Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.
The nurse is caring for a hospitalized patient who has a moderate bilateral headache that radiates from the base of the skull. Which of the following prescribed PRN medications should the nurse administer initially?
- A. Lorazepam
- B. Acetaminophen
- C. Morphine sulphate
- D. Butalbital and Aspirin
Correct Answer: B
Rationale: The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulphate or butalbital and Aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.
The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. Which of the following actions is priority for the nurse to take initially?
- A. Assess the patient for a possible head injury.
- B. Give the scheduled dose of divalproex
- C. Document the timing and description of the seizure.
- D. Notify the patient's health care provider about the seizure.
Correct Answer: A
Rationale: The patient who has had a myoclonic seizure and fall is at risk for head injury and should be evaluated and treated for this possible complication first. Documentation of the seizure, notification of the seizure, and administration of antiseizure drugs also are appropriate actions, but the initial action should be assessment for injury.
A patient was noted to have a generalized seizure reports afterward that the seizure was preceded by numbness and tingling of the arm. What type of seizure would this be classified as?
- A. Atonic
- B. Partial
- C. Absence
- D. Myoclonic
Correct Answer: B
Rationale: The initial symptoms of a partial seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.
Which of the following prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonic-clonic seizures?
- A. Give phenytoin 100 mg IV.
- B. Monitor level of consciousness.
- C. Obtain computed tomography scan.
- D. Administer lorazepam 4 mg IV.
Correct Answer: D
Rationale: To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure drugs such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin also will be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.