The nurse should complete which essential interventions for a patient who has experienced status epilepticus?

Administer a dose of a prescribed antiepileptic drug and position the person supine.

Wrap the patient in warm blankets and hyperextend their neck.

Offer the patient a crossword to work on to promote mental stimulation.

Establish that the patient has a patent airway after the seizure ends and assess for breathing.

Answer and Explanation

The Correct Answer is D

Choice A reason: This is incorrect. Administering a dose of a prescribed antiepileptic drug is an appropriate intervention, but it should be done during the seizure, not after. Positioning the person supine is also not recommended, as it can compromise the airway and increase the risk of aspiration.

Choice B reason: This is incorrect. Wrapping the patient in warm blankets and hyperextending their neck are both harmful actions, as they can increase the body temperature and obstruct the airway. The patient should be kept cool and comfortable, and their head should be tilted to the side or supported with a pillow.

Choice C reason: This is incorrect. Offering the patient a crossword to work on to promote mental stimulation is not an essential intervention, and it may not be feasible or appropriate for a patient who has just experienced a prolonged seizure. The patient may need rest and observation, not cognitive tasks.

Choice D reason: This is correct. Establishing that the patient has a patent airway after the seizure ends and assessing for breathing are the most important interventions, as they ensure the oxygenation and ventilation of the patient. The nurse should also monitor the vital signs, neurological status, and blood glucose levels of the patient.

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Correct Answer is C

Explanation

Choice A reason: Relaxing in a hot bath before bedtime is not the best suggestion to help decrease fatigue for a patient with multiple sclerosis. Heat can worsen the symptoms of multiple sclerosis, such as muscle weakness, numbness, and vision problems. Therefore, the patient should avoid hot baths, showers, or saunas, and use cool compresses or fans to lower their body temperature.

Choice B reason: Performing deep breathing exercises every two hours is not the best suggestion to help decrease fatigue for a patient with multiple sclerosis. Deep breathing can help reduce stress and anxiety, but it does not address the underlying causes of fatigue, such as inflammation, nerve damage, or sleep problems. Therefore, the patient should consult their doctor for appropriate treatment options and medication adjustments.

Choice C reason: Scheduling short periods of rest throughout the day is the best suggestion to help decrease fatigue for a patient with multiple sclerosis. Fatigue is a common and disabling symptom of multiple sclerosis, which can affect the patient's daily activities and quality of life. Therefore, the patient should plan their tasks according to their energy level, prioritize the most important ones, and take frequent breaks to conserve their energy and prevent exhaustion.

Choice D reason: Including daily multivitamins in your diet is not the best suggestion to help decrease fatigue for a patient with multiple sclerosis. Multivitamins can provide some nutritional benefits, but they are not a substitute for a balanced and healthy diet. Therefore, the patient should eat a variety of foods, such as fruits, vegetables, whole grains, lean proteins, and low-fat dairy, and avoid processed, fried, or sugary foods that can increase inflammation and fatigue.

A. Elevate the head of the bed 20 to 30 degrees. B. Maintain bright lighting in the room to assess bleeding at the surgical site. C. Stimulate the patient every half hour to assess changes in level of consciousness. D. Allow the patient to change positions frequently to maintain comfort.

Correct Answer is A

Explanation

Choice A reason: Elevating the head of the bed 20 to 30 degrees is an appropriate intervention for a patient who had a craniotomy to relieve increased intracranial pressure. It helps to reduce the venous pressure and improve the cerebral perfusion.

Choice B reason: Maintaining bright lighting in the room to assess bleeding at the surgical site is not an appropriate intervention for a patient who had a craniotomy to relieve increased intracranial pressure. It can increase the sensory stimulation and aggravate the intracranial pressure. The nurse should use dim lighting and monitor the dressing and the drainage system for signs of bleeding.

Choice C reason: Stimulating the patient every half hour to assess changes in level of consciousness is not an appropriate intervention for a patient who had a craniotomy to relieve increased intracranial pressure. It can increase the cerebral metabolic demand and worsen the intracranial pressure. The nurse should assess the level of consciousness using the Glasgow Coma Scale and avoid unnecessary stimulation.

Choice D reason: Allowing the patient to change positions frequently to maintain comfort is not an appropriate intervention for a patient who had a craniotomy to relieve increased intracranial pressure. It can increase the intrathoracic pressure and affect the cerebral blood flow. The nurse should limit the patient's movement and avoid extreme flexion, extension, or rotation of the head and neck.

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The nurse should complete which essential interventions for a patient who has experienced status epilepticus?

Nursing Test Bank

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Correct Answer is A

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