A client presents to the emergency department actively having seizure activity.
The paramedics report the client has a history of epilepsy but her family doesn't know the names of her current medications.
The priority for this patient is:

Obtain a blood specimen to check for serum drug levels.

Administer lorazepam IV to stop the convulsive activity.

Check the client's blood pressure and heart rate.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Checking serum drug levels provides insight into compliance and effectiveness but doesn’t address immediate seizure cessation, prioritizing treatment over diagnostic assessment.

Choice B rationale

Administering lorazepam IV halts seizure activity quickly by enhancing GABA activity, calming neuronal excitation, and stabilizing the patient’s condition, reducing potential complications.

Choice C rationale

Monitoring vitals like blood pressure and heart rate is essential but doesn’t directly address convulsive activity, which requires immediate pharmacological intervention to prevent status epilepticus progression. .

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Correct Answer is C

Explanation

Choice A rationale

Monitoring and documenting findings without intervention ignores the critical need to manage intracranial pressure (ICP). Normal ICP is 7-15 mmHg, and 25 mmHg indicates a dangerous elevation requiring prompt corrective actions.

Choice B rationale

Suctioning can trigger a vagal response, further increasing ICP. Interventions should aim to decrease ICP, not exacerbate it. Careful suctioning is used when airway clearance is critical, not as a routine measure.

Choice C rationale

Raising the head of the bed to 35–45 degrees promotes venous drainage, reducing ICP. Alerting the physician ensures timely medical interventions. This is the primary recommended action for elevated ICP cases.

Choice D rationale

Lowering the head of the bed can worsen ICP by impairing venous outflow. Padded side rails are useful for seizure precautions but are irrelevant for managing elevated ICP in this situation.

A. Ensure bed alarm is on when leaving the patient's room. B. Clarify misinformation and reorient the patient when confused. C. Turn the patient every 2 hours to prevent skin breakdown. D. Vary the schedule to prevent memorization and boredom.

Correct Answer is A

Explanation

Choice A rationale

Cerebellar injury affects balance and coordination; ensuring bed alarm use prioritizes safety for patients who are at high fall risk due to impaired motor control and unsteady gait.

Choice B rationale

Reorientation addresses confusion, often linked to cognitive or frontal brain injuries, not cerebellar function, which mainly regulates coordination and balance rather than higher-order thinking.

Choice C rationale

Turning every 2 hours prevents skin breakdown but is more relevant to immobilized patients, not those with cerebellar injuries where mobility and fall prevention are the primary concerns.

Choice D rationale

Varying the schedule may stimulate engagement but does not directly address fall risks or coordination issues, which are critical for patients with cerebellar injuries.

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A client presents to the emergency department actively having seizure activity.The paramedics report the client has a history of epilepsy but her family doesn't know the names of her current medications.The priority for this patient is:

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A client presents to the emergency department actively having seizure activity.
The paramedics report the client has a history of epilepsy but her family doesn't know the names of her current medications.
The priority for this patient is: