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.
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Reviewing the safety data sheet does not directly alleviate the immediate chemical injury or prevent further damage. Immediate irrigation of the eyes is the priority after chemical exposure to minimize damage to the ocular surface.
Choice B rationale
Continuous irrigation removes chemical agents from the eyes and prevents further damage. Ensuring a pain-free state and checking pH confirm the removal of irritants, essential for preventing deeper eye tissue damage.
Choice C rationale
Miotic drops reduce intraocular pressure but do not address acute chemical injury. Pain relief is secondary to irrigating and neutralizing pH, which directly prevents ongoing tissue damage and irritation.
Choice D rationale
Assessing visual acuity and vital signs is important but secondary to preventing further chemical penetration. Immediate irrigation prevents damage progression and is prioritized over assessments during the acute phase of exposure.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
A decreased level of consciousness indicates possible intracranial hemorrhage, a complication of thrombolytic therapy. Altered mental status may result from brain bleeding disrupting normal neural function.
Choice B rationale
Elevated blood pressure and headache suggest intracranial hemorrhage, as the rise in intracranial pressure often accompanies vascular disruption and neurogenic pain.
Choice C rationale
Vomiting and persistent nausea can signal intracranial hemorrhage, as blood irritating brain tissue and increasing pressure stimulates the emetic center in the medulla.
Choice D rationale
Positive Babinski's sign is associated with upper motor neuron lesions but is not a direct indicator of thrombolytic therapy complications such as intracranial bleeding.
Choice E rationale
Fever and cardiac dysrhythmias do not directly indicate thrombolytic therapy complications. Dysrhythmias may stem from electrolyte disturbances or infections unrelated to hemorrhage.
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