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

Speaking at increased speed may hinder comprehension in individuals with sensorineural hearing loss, as clarity diminishes with rapid verbalization.

Choice B rationale

Reducing caffeine intake is irrelevant to auditory function; caffeine influences systemic effects but does not aid hearing impairment.

Choice C rationale

Facing the individual directly ensures clear visual cues, including lip reading, critical for communication with sensorineural hearing loss.

Choice D rationale

Varying pitch disrupts consistency in auditory perception; maintaining a steady tone aids clarity for impaired auditory processing.

A. Prepare to administer recombinant tissue plasminogen activator (t-PA). B. Assist with transport to a STAT non-contrast computed tomography scan of the head. C. Perform a STAT EKG and assist with a STAT chest X-ray. D. Notify the speech and language pathologist for a STAT dysphagia evaluation.

Correct Answer is B

Explanation

Choice A rationale

Administering recombinant tissue plasminogen activator (t-PA) may be necessary, but confirming ischemic stroke via CT scan precedes treatment to rule out hemorrhagic stroke, which contraindicates t-PA.

Choice B rationale

Performing a STAT non-contrast CT scan of the head is the priority to differentiate between ischemic and hemorrhagic stroke, enabling appropriate and timely intervention.

Choice C rationale

A STAT EKG and chest X-ray, though helpful in identifying concurrent cardiac or pulmonary issues, are not immediate priorities in acute stroke evaluation.

Choice D rationale

While assessing dysphagia is critical post-stroke, it is not a priority during initial stroke evaluation, which focuses on rapid imaging and differentiation of stroke type. .

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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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: