The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

Drug dependence

Cardiac rhythm

Pulse oximetry

Pain level

Answer and Explanation

The Correct Answer is C

A. While drug dependence can be a concern with long-term use, it is not the immediate priority in an emergency setting where the goal is to stabilize the patient in status epilepticus.

B. Cardiac rhythm monitoring is important when administering certain medications, but lorazepam primarily affects the central nervous system and respiratory system, making oxygen saturation monitoring more critical.

C. Pulse oximetry is the priority assessment as IV lorazepam can depress the respiratory system, leading to hypoxia. Monitoring oxygen saturation helps ensure the patient maintains adequate respiratory function during administration.

D. Assessing pain is important in patient care, but it is not the priority in managing a patient in status epilepticus, where stabilization is essential.

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Correct Answer is D

Explanation

A. Posterior cord injury usually affects proprioception rather than causing a distinctive pattern of motor and sensory loss.

B. Anterior cord injury generally impacts motor function and temperature and pain sensation bilaterally, not in a hemisection pattern.

C. Central cord injury primarily affects motor function in the upper extremities and is not characterized by ipsilateral motor and contralateral sensory loss.

D. Brown-Sequard syndrome typically presents with motor function loss on the same (ipsilateral) side of the injury and loss of pain and temperature sensation on the opposite (contralateral) side, making this the most likely diagnosis.

A. Use a draw sheet to move the patient B. Have the patient grasp the side rail and assist with turning C. Cross the lower extremities, turn the hips then turn the shoulders D. With one person holding the head, 2 others log roll the client as a unit

Correct Answer is D

Explanation

A. Using a draw sheet may cause twisting, which can compromise spinal alignment.

B. Asking the patient to assist may risk further spinal injury.

C. Turning hips and shoulders separately risks disrupting spinal alignment, making this an unsafe approach.

D. Log rolling is the safest way to turn a patient with a spinal cord injury, maintaining spinal alignment and preventing further injury. It requires one person to stabilize the head while others turn the body as a single unit.

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ABG Value	Normal Range
pH	7.35- 7.45
PaCO2	35-45 mm Hg
HCO3	22-25 mEq/L
Base excess	-2 to +2
PaO2	80-95 mm Hg
SaO2	>95%

The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is preparing to turn the patient who sustained a spinal cord injury. How should the nurse proceed?

Correct Answer is D

Explanation

The nurse on the brain injury unit observes a patient who displays inappropriate sexual behavior. What would be the best response by the nurse?

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