A nurse is caring for a patient who has just experienced a tonic-clonic seizure. Which of the following actions should the nurse perform first after ensuring the patient's safety?

Document the seizure activity in the patient's medical record.

Check the patient's vital signs

Administer oral antiepileptic medication.

Place the patient in a side-lying position.

Answer and Explanation

The Correct Answer is D

A.   Documenting the seizure activity is important but should be done after addressing immediate needs.
B.   Checking the patient's vital signs is important but is secondary to positioning the patient safely to prevent aspiration.
C.   Administering oral antiepileptic medication is necessary but not the first action following a tonic- clonic seizure.
D.   Placing the patient in a side-lying position immediately after the seizure ensures that the airway remains open and reduces the risk of aspiration.

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Correct Answer is C

Explanation

A. Dextrose 10% in water is hypertonic and would exacerbate hypernatremia by further increasing sodium levels.
B. 25% albumin is not appropriate for treating hypernatremia and is typically used for volume expansion in cases of shock or hypoalbuminemia.
C. Dextrose 5% in water is an isotonic solution that helps dilute sodium levels and correct hypernatremia gradually.
D. Dextran 40 is a volume-expanding agent, not suitable for treating hypernatremia.

A. Assume the episode was a migraine and schedule a neurology follow-up for a later date. B. Discharge the patient immediately since the symptoms resolved. C. Initiate antiplatelet therapy, such as aspirin, to reduce the risk of future strokes. D. Order a CT scan of the head to rule out intracranial hemorrhage. E. Start anticoagulation therapy immediately without further evaluation. F. Conduct a carotid ultrasound to assess for stenosis. G. Refer the patient for lifestyle modifications, including smoking cessation and diet changes.

Correct Answer is ["C","D","F","G"]

Explanation

A. Assuming the episode was a migraine and scheduling a follow-up is not appropriate. TIAs are serious warning signs of potential future strokes and require immediate attention and evaluation.
B. Discharging the patient immediately after symptoms resolve is not appropriate. Even though symptoms resolve, TIAs are medical emergencies, and further evaluation is necessary to reduce the risk of a full-blown stroke.
C. Initiating antiplatelet therapy, such as aspirin, is an appropriate action to reduce the risk of future strokes in patients who have had a TIA.
D. Ordering a CT scan of the head is appropriate to rule out an intracranial hemorrhage and other causes of the symptoms.

E. Starting anticoagulation therapy immediately without further evaluation is not recommended. The patient must be properly assessed before starting anticoagulation to determine the cause of the TIA and if anticoagulation is appropriate.
F. Conducting a carotid ultrasound is appropriate to assess for stenosis, which could be contributing to the TIA.
G. Referring the patient for lifestyle modifications, including smoking cessation and diet changes, is crucial to reduce future stroke risk. These interventions help prevent the recurrence of TIAs and strokes.

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A nurse is caring for a patient who has just experienced a tonic-clonic seizure. Which of the following actions should the nurse perform first after ensuring the patient's safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has hypernatremia. Which of the following IV solutions should the nurse plan to initiate?

Correct Answer is C

Explanation

Correct Answer is ["C","D","F","G"]

Explanation

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