The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipate administering to halt the seizure immediately?

Intravenous phenobarbital.

Oral phenytoin.

Intravenous diazepam.

Oral lorazepam.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Intravenous phenobarbital can be used to treat status epilepticus, but it is not the first-line drug due to its slower onset of action compared to benzodiazepines. Rapid intervention is critical in status epilepticus, and phenobarbital is generally reserved for refractory cases.

Choice B rationale

Oral phenytoin is used for long-term control of seizures but is not effective for immediate cessation of status epilepticus. It takes longer to reach therapeutic levels and is not suitable for acute management.

Choice C rationale

Intravenous diazepam is a benzodiazepine with a rapid onset of action, making it effective in stopping seizures immediately. It enhances GABA activity, which has an inhibitory effect on neuronal firing, providing quick control of status epilepticus. This rapid effect is crucial for minimizing neuronal damage and other complications.

Choice D rationale

Oral lorazepam is effective for long-term management of seizures but is not appropriate for immediate treatment of status epilepticus. The oral route delays absorption and onset of action, making it unsuitable for acute seizure control. .

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Correct Answer is D

Explanation

Choice A rationale

The spinal accessory nerve (cranial nerve XI) controls the sternocleidomastoid and trapezius muscles, which are responsible for movements of the head and shoulders. Dysfunction in this nerve would not affect the gag reflex.

Choice B rationale

The acoustic nerve (cranial nerve VIII) is responsible for hearing and balance. Dysfunction in this nerve would lead to hearing loss and balance issues, not an absent gag reflex.

Choice C rationale

The facial nerve (cranial nerve VII) controls muscles of facial expression and functions in the conveyance of taste sensations from the anterior two-thirds of the tongue. Dysfunction here results in facial paralysis or weakness but not in the absence of a gag reflex.

Choice D rationale

The vagus nerve (cranial nerve X) innervates muscles of the pharynx and larynx, which are involved in swallowing and the gag reflex. Dysfunction in the vagus nerve would result in an absent gag reflex, which is why the nurse determines this as the issue.

A. Administer a bolus of normal saline as prescribed. B. Administer bronchodilators as prescribed and monitor the client's LOC. C. Increase the client's bed height and reassess in 30 minutes. D. Inform the care team and assess for further signs of possible increased ICP.

Correct Answer is D

Explanation

Choice A rationale

Administering a bolus of normal saline may not directly address the cause of increased respiratory effort, which could be related to increased intracranial pressure (ICP). Normal saline administration is not the priority intervention in this case.

Choice B rationale

Bronchodilators are used to manage bronchoconstriction, not increased respiratory effort due to potential increased ICP. Monitoring the client's level of consciousness (LOC) is important, but bronchodilators are not indicated here.

Choice C rationale

Increasing the client's bed height can help with respiratory effort, but it does not directly address the potential underlying issue of increased ICP. Reassessing in 30 minutes might delay necessary interventions.

Choice D rationale

Increased respiratory effort in a client with a head injury may indicate rising ICP. Informing the care team and assessing for further signs of increased ICP is crucial for timely intervention to prevent further complications.

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The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipate administering to halt the seizure immediately?

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Naxlex Comprehensive Predictor Exams

A client is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the client has?

Correct Answer is D

Explanation

The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate action?

Correct Answer is D

Explanation

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The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipate administering to halt the seizure immediately?

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