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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 D

Explanation

A. The head tilt chin lift method should be avoided due to the risk of aggravating a spinal injury; the jaw-thrust maneuver is safer if airway management is necessary.

B. While controlling bleeding is important, cervical spine stabilization takes priority in trauma with suspected spinal injury.

C. Not moving the victim is appropriate, but stabilizing the cervical spine provides active support to avoid further injury.

D. Stabilizing the cervical spine is crucial to prevent potential spinal cord damage in an unconscious trauma victim, particularly in a motor vehicle accident. This action helps prevent exacerbation of any spinal injury.

A. Administer antibiotics due to increased risk of infection B. Prevent the drainage by applying a pressure dressing C. Hang intravenous (IV) fluids to replace fluids lost D. Allow fluid to drain from the patient's ear onto gauze and notify provider

Correct Answer is D

Explanation

A. Antibiotics may be necessary if infection is confirmed, but this is not the priority action.

B. Applying a pressure dressing could increase intracranial pressure or worsen the injury.

C. IV fluids can be helpful in managing shock but are not directly related to CSF leakage management.

D. Yellowish fluid from the ear, which creates a "halo" or yellow ring around it on gauze, may indicate cerebrospinal fluid (CSF) leakage. This is a sign of a potential skull fracture and requires prompt provider notification. Allowing the fluid to drain and collecting it can provide necessary information about the injury.

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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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