A patient is admitted to the Emergency Department (ED). The nurse documents "postictal upon transfer" as evidenced by which observation?
Abnormal sensory sensations including tingling of the skin
Yellowing of the skin
Severe itching of the eyes
Is in a drowsy confused state after a seizure
The Correct Answer is D
A. Abnormal sensory sensations such as tingling may be associated with the aura phase of a seizure but are not typically observed postictally.
B. Yellowing of the skin is usually indicative of jaundice, unrelated to seizure activity or the postictal state.
C. Itching of the eyes is unrelated to seizure activity and would not typically be documented in the context of postictal observations.
D. The postictal state is characterized by drowsiness, confusion, and other altered mental statuses that follow a seizure. This period can vary in duration depending on the patient and seizure type.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A cold, pulseless foot indicates compromised blood flow, a medical emergency following an arteriogram. The nurse should immediately notify the physician to address potential vascular occlusion.
B. Elevating the limb can further impair circulation if blood flow is already compromised.
C. Covering the limb will not address the underlying issue of impaired circulation.
D. Repositioning may delay timely intervention in what may be a vascular emergency.
Correct Answer is D
Explanation
A. Anesthetic eye drops can help with pain, but irrigation is the priority to prevent further damage.
B. A visual acuity exam is part of the assessment but should be performed after initial irrigation to prevent further damage.
C. Determining the pH of the chemical splash can guide further treatment but is secondary to immediate irrigation to dilute and remove the chemical.
D. Irrigating both eyes with normal saline is the priority action to dilute and flush out the chemical, reducing the risk of further injury.
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