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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.
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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.
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.
The nurse is assessing a patient at the health clinic who has a severe migraine headache and tells the nurse about having four similar headaches in the last 3 months. Which of the following actions should the nurse take initially?
- A. Refer the patient for stress counselling.
- B. Ask the patient to keep a headache diary.
- C. Suggest the use of muscle-relaxation techniques.
- D. Teach about the effectiveness of the triptan drugs.
Correct Answer: B
Rationale: The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first.
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.
Which action will the nurse take when evaluating a patient who is taking phenytoin for adverse effects of the medication?
- A. Inspect the oral mucosa.
- B. Listen to the lung sounds.
- C. Auscultate the bowel tones.
- D. Check pupil reaction to light.
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light.