The nurse is providing care for a patient in status epilepticus. What nursing intervention takes the highest priority?

Maintain a patent airway

Place an intravenous catheter (IV)

Administer diazepam, per order

Insert a nasogastric tube (NG)

Answer and Explanation

The Correct Answer is A

Choice A rationale
Maintaining a patent airway is the highest priority when providing care for a patient in status epilepticus. Status epilepticus is a medical emergency characterized by prolonged or recurrent seizures. It can lead to severe complications, including respiratory distress and hypoxia.
Therefore, ensuring a patent airway is crucial to prevent hypoxia and further brain damage. This involves positioning the patient to prevent aspiration, potentially suctioning the airway, and providing supplemental oxygen as needed.
Choice B rationale
While placing an intravenous catheter (IV) is an important intervention, it is not the highest priority. An IV allows for the administration of medications and fluids, which are necessary in the management of status epilepticus. However, it is secondary to maintaining a patent airway.
Choice C rationale
Administering diazepam or other antiepileptic drugs is a key intervention in managing status epilepticus. These medications help to stop the seizures. However, medication administration should only occur after a patent airway has been established.
Choice D rationale
Inserting a nasogastric tube (NG) may be necessary in some cases to protect the airway or for administering medications or nutrition. However, this is not the highest priority intervention. The first step in managing status epilepticus is always to ensure a patent airway.

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Correct Answer is A

Explanation

Choice A rationale
Triptans, a class of medications commonly used to treat migraines, can cause vasoconstriction, or narrowing of the blood vessels. This can be problematic for patients with angina, a condition characterized by reduced blood flow to the heart. Vasoconstriction could potentially exacerbate this condition, leading to an increased risk of a heart attack. Therefore, the use of triptans may be contraindicated in patients with angina.

Choice B rationale
While asthma is a serious condition that requires careful management, it is not typically considered a contraindication for the use of triptans. Triptans work primarily on the blood vessels in the brain and do not typically interact with the bronchial tubes affected by asthma.
Choice C rationale
Age alone is not typically a contraindication for the use of triptans. However, older adults may have a higher risk of certain health conditions, such as heart disease, which could make the use of triptans more risky. It’s important for healthcare providers to consider the overall health status of the patient, not just their age, when deciding whether to prescribe triptans.
Choice D rationale
While stress can certainly exacerbate migraines, it is not typically a contraindication for the use of triptans. Triptans are designed to relieve the pain and other symptoms of migraines, regardless of their cause. If a patient’s migraines are triggered by stress, it may be beneficial to explore stress management techniques in addition to medication.

A. “I will need to take edrophonium to treat the disease.”. B. “This disease is a disorder of motor and sensory dysfunction.”. C. “This disease doesn’t cause sensory impairment.”. D. “I will continue to experience progressive muscle weakness and sensory deficits.”.

Correct Answer is A

Explanation

Choice A rationale
Myasthenia gravis is a neuromuscular disorder characterized by weakness and fatigue of voluntary muscles. Edrophonium is a medication that is used in the diagnosis and treatment of myasthenia gravis. It works by inhibiting the breakdown of acetylcholine, a neurotransmitter that transmits signals in the nervous system, thereby improving muscle strength.
Choice B rationale
Myasthenia gravis is not a disorder of motor and sensory dysfunction. It primarily affects the neuromuscular junction, leading to muscle weakness and fatigue. Sensory function is typically not affected in myasthenia gravis.
Choice C rationale
This statement is correct in that myasthenia gravis does not cause sensory impairment. However, it does not indicate an understanding of the disease as a whole, as it does not address the primary symptom of muscle weakness.
Choice D rationale
Myasthenia gravis does cause progressive muscle weakness, but it does not cause sensory deficits. Therefore, this statement indicates a partial understanding of the disease.

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The nurse is providing care for a patient in status epilepticus. What nursing intervention takes the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient with a recent history of migraines. What aspect of this patient’s current status may contraindicate the safe use of triptans?

Correct Answer is A

Explanation

A nurse is educating a client recently diagnosed with myasthenia gravis. Which statement made by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

In the context of an initial assessment for a client admitted to rule out Guillain-Barre syndrome, which of the following symptoms would the nurse expect to observe?

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The nurse is providing care for a comatose patient and regularly assessing for potential complications. What complications should the nurse be looking for?

The nurse is providing care for a patient in status epilepticus. What nursing intervention takes the highest priority?

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