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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 A

Explanation

A. Elevating the head of the bed, loosening clothing, and checking for urinary catheter obstruction are key steps to lower blood pressure and relieve triggers of autonomic dysreflexia, a potentially life-threatening condition.

B. A cool compress may provide comfort but does not directly address the primary triggers or symptoms of autonomic dysreflexia.

C. Semi-Fowler's position is insufficient compared to a full 90-degree sitting position, which helps reduce blood pressure.

D. IV access and oxygen may be required if symptoms do not resolve, but immediate actions focus on relieving the cause of dysreflexia.

A. after the client has an electroencephalogram (EEG)." B. due to having minimal risk for infection." C. by threading it through the femoral artery to the brain." D. to monitor intracranial pressure (ICP) and drain the cerebral spinal fluid."

Correct Answer is D

Explanation

A. EEG is a monitoring tool for brain activity, but it is not a prerequisite for ventriculostomy placement.

B. While the procedure is carefully managed to reduce infection risk, ventriculostomy does have an infection risk due to its invasive nature.

C. Ventriculostomy is not inserted via the femoral artery; it is placed directly in the brain’s ventricles.

D. A ventriculostomy is used to monitor ICP and allows for the drainage of cerebrospinal fluid, which helps in managing elevated ICP in patients with brain injuries.

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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

The nurse suspects autonomic dysreflexia in the patient with a spinal cord injury at the level of C-7. After checking vital signs what are the priority nursing interventions?

Correct Answer is A

Explanation

The nurse is educating on the placement of a ventriculostomy (intraventricular catheter) to the patient diagnosed with a brain injury and their family. The nurse states, "The ventriculostomy is placed:

Correct Answer is D

Explanation

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