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 B

Explanation

Choice A rationale
While tremors and decreased mobility are common symptoms of Parkinson’s disease, they are not the most significant impact on a patient’s life. These physical symptoms can be managed with medication and physical therapy.
Choice B rationale
Loss of independence is often the most significant impact on a patient’s life. As the disease progresses, patients may find it increasingly difficult to perform daily activities and may require assistance.

Choice C rationale
Age-related changes can contribute to the progression of Parkinson’s disease, but they are not the most significant impact on a patient’s life. The disease itself, rather than aging, is the primary cause of the symptoms.
Choice D rationale
Neurologic deficits are a result of Parkinson’s disease, but they are not the most significant impact on a patient’s life. The loss of independence that results from these deficits is often more impactful.

A. Administering hydromorphone as needed B. Distracting the patient with activity C. Dimming the lights and reducing stimulation D. Initiating a patient-controlled analgesia (PCA) of morphine sulfate .

Correct Answer is C

Explanation

Choice C rationale
Dimming the lights and reducing stimulation can be an effective nursing intervention for a patient with herpes simplex virus encephalitis who is complaining of a headache. Bright lights and excessive noise can exacerbate headaches, so creating a quiet, dimly lit environment can help to alleviate this symptom.
Choice A rationale

While administering hydromorphone as needed can help to manage the patient’s pain, it does not directly address the patient’s complaint of a headache. Moreover, opioids like hydromorphone can have side effects such as drowsiness and constipation, which may not be desirable in a patient with encephalitis.
Choice B rationale
Distracting the patient with activity may not be appropriate for a patient with herpes simplex virus encephalitis who is complaining of a headache. Rest and quiet are often more beneficial for these patients.
Choice D rationale
Initiating a patient-controlled analgesia (PCA) of morphine sulfate can provide effective pain relief for some patients, but it may not be the best first-line approach for a patient with a headache due to herpes simplex virus encephalitis. Like hydromorphone, morphine can have side effects such as drowsiness and constipation.

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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

Correct Answer is B

Explanation

A patient is being admitted to the unit with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient’s complaints of headache?

Correct Answer is C

Explanation

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