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The nurse is performing the morning assessment on a patient. The patient suddenly screams loudly and begins to have a generalized tonic/clonic type seizure. What is the priority nursing intervention?

Place soft restraints on the patient

Place a padded tongue blade in the client's mouth

Turn the patient on the side and stay with them

Immediately go to the nurses' station for help

Respirations

Answer and Explanation

The Correct Answer is C

A. Soft restraints are not recommended during a seizure and can cause harm to the patient.

B. Placing anything in the mouth during a seizure can lead to injury or airway obstruction and is contraindicated.

C. Turning the patient on their side helps to maintain an open airway and prevent aspiration; staying with the patient ensures ongoing monitoring.

D. Leaving the patient alone to seek help is unsafe, as it leaves the patient unmonitored during the seizure.

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Correct Answer is B

Explanation

A. A hearing test does not address the infection symptoms and would not be the priority.

B. Obtaining a culture of the drainage is necessary to identify any infection and guide appropriate antibiotic treatment.

C. Removing a foreign body may not be relevant and could worsen infection symptoms if not necessary.

D. A CT scan may be needed if further complications are suspected, but it is not the priority for infection symptoms.

A. was found facedown in water for unknown length of time. B. has had multiple concussions in a short period of time. C. was in an assault resulting in a basilar skull fracture. D. suffered an epidural hematoma.

Correct Answer is A

Explanation

A. A patient found facedown in water is at high risk of anoxic brain injury due to potential prolonged oxygen deprivation, which is directly associated with lack of oxygen to the brain.

B. Multiple concussions can lead to other types of brain injury but are less associated with anoxic injury than prolonged oxygen deprivation.

C. A basilar skull fracture can cause complications such as CSF leaks but does not directly cause an anoxic brain injury.

D. An epidural hematoma may increase ICP, but with timely intervention, anoxic injury may be avoided; anoxic brain injury is more directly related to oxygen deprivation.

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The nurse is performing the morning assessment on a patient. The patient suddenly screams loudly and begins to have a generalized tonic/clonic type seizure. What is the priority nursing intervention?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

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