Which prescribed intervention should the emergency department nurse implement first for a patient who is experiencing continuous tonic-clonic seizures?

Monitor level of consciousness (LOC)

Administer lorazepam (Ativan) 4 mg IV.

Obtain computed tomography (CT) scan.

Give phenytoin (Dilantin) 100 mg IV.

Answer and Explanation

The Correct Answer is B

A. Monitor level of consciousness (LOC): While monitoring the patient's level of consciousness is important, administering medication to stop the seizure takes precedence to prevent potential complications associated with prolonged seizure activity.

B. Administer lorazepam (Ativan) 4 mg IV: The priority in managing continuous tonic-clonic seizures is to terminate the seizure activity promptly. Lorazepam is a benzodiazepine that can help to abort seizures and is often used as first-line treatment in the acute setting.

C. Obtain computed tomography (CT) scan: While obtaining diagnostic imaging such as a CT scan may be necessary to evaluate for underlying causes of the seizure, it is not the first
intervention in the acute management of continuous seizures. Stabilizing the patient and stopping the seizure activity take precedence.

D. Give phenytoin (Dilantin) 100 mg IV: Phenytoin is an antiepileptic medication that is used for long-term management of seizures but is not typically administered as first-line treatment during an acute seizure episode. Benzodiazepines like lorazepam are preferred for immediate seizure control.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. "Engage in a vigorous exercise program." This statement may not be suitable for a client with multiple sclerosis experiencing symptoms such as diplopia, dysmetria, and sensory changes. While exercise is beneficial for managing MS symptoms, it should be tailored to the individual's abilities and symptoms.

B. "Plan to relax in a hot tub spa each day." Hot tubs can exacerbate symptoms of multiple sclerosis, particularly heat sensitivity. Therefore, this statement is not appropriate for this client.

C. "Implement a schedule to include periods of rest." Fatigue is a common symptom of multiple sclerosis, and incorporating regular periods of rest into the daily schedule can help manage fatigue and conserve energy.

D. "Wear an eye patch on the right eye at all times." While wearing an eye patch may help alleviate diplopia (double vision), it is not typically recommended for continuous use and should be used under the guidance of an ophthalmologist or healthcare provider.

A. Restrain the patient's arms and legs to prevent injury during the seizure. B. Time and observe and record the details of the seizure and postictal state. C. Insert an oral airway during the seizure to maintain a patent airway. D. Avoid touching the patient to prevent further nervous system stimulation.

Correct Answer is B

Explanation

A. Restrain the patient's arms and legs to prevent injury during the seizure: Restraint during a seizure can potentially cause harm to the patient and should be avoided. It is essential to ensure the patient's safety by protecting the head and providing a safe environment.

B. Time and observe and record the details of the seizure and postictal state: Timing the seizure, observing the type and duration of movements, and noting any changes in the patient's behavior during the postictal state are crucial for documenting the seizure accurately and guiding further management.

C. Insert an oral airway during the seizure to maintain a patent airway: Inserting an oral airway during an active seizure is not recommended and can increase the risk of injury to the patient's airway. Maintaining a clear airway is important, but interventions such as positioning and
suctioning may be sufficient without the need for airway adjuncts during the seizure.

D. Avoid touching the patient to prevent further nervous system stimulation: While it's essential to minimize stimulation during a seizure, avoiding touching the patient altogether may not be feasible or necessary for providing care. Ensuring a safe environment and providing appropriate support are priorities during a seizure.

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Which prescribed intervention should the emergency department nurse implement first for a patient who is experiencing continuous tonic-clonic seizures?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?

Correct Answer is C

Explanation

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Correct Answer is B

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