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)
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Analgesics can be used to manage pain associated with Bell’s palsy. Therefore, this statement does not indicate a need for further education.
Choice B rationale
This is the correct answer. Chewing on the affected side can actually exacerbate swallowing issues. Therefore, this statement indicates a need for further education.
Choice C rationale
Brushing teeth should not be affected by Bell’s palsy. Therefore, this statement does not indicate a need for further education.
Choice D rationale
Applying a protective eye shield before going to bed is a recommended practice for patients with Bell’s palsy. This helps to protect the eye from injury and keep it moist, as Bell’s palsy can cause difficulty in blinking or closing the eye.
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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