While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

Observe for prolonged periods of apnea.

Observe for lacerations to the tongue.

Document details of the seizure activity.

Evaluate for evidence of incontinence.

Answer and Explanation

The Correct Answer is A

A.   This intervention is important for assessing the client's respiratory status during and after the seizure. Apnea can cause cardiac arrest and respiratory failure and hence a priority.
B.   This intervention is crucial for assessing potential injury to the client's mouth or tongue, which can occur during a seizure due to involuntary muscle movements. However, before assessing for lacerations, the nurse should prioritize ensuring the client's safety.
C.   Documenting details of the seizure activity is important for maintaining accurate medical records and providing information to the healthcare team. However, before documenting details of the seizure, the nurse should prioritize ensuring the client's safety and providing immediate assistance during the seizure. Therefore, while documentation is essential, it may not be the first intervention to implement.
D.   While evaluating for incontinence is important for addressing the client's immediate needs and ensuring comfort, it may not be the first intervention to implement. The nurse should prioritize ensuring the client's safety and providing immediate assistance during the seizure.

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Correct Answer is B

Explanation

B. Acute pancreatitis is inflammation of the pancreas that can cause severe upper abdominal pain, which may radiate to the back, fever, and vomiting. Elevated serum amylase and lipase levels are characteristic laboratory findings in acute pancreatitis, indicating pancreatic injury or inflammation. The client's symptoms and laboratory results are consistent with acute pancreatitis.
A. Hepatorenal failure, also known as hepatorenal syndrome, is a serious complication of advanced liver disease where there is progressive renal failure in the setting of liver dysfunction. While hepatorenal syndrome can present with symptoms such as abdominal pain, fever, and vomiting, it is not typically associated with significantly elevated serum amylase and lipase levels.
C. Biliary duct obstruction occurs when there is a blockage in the bile ducts, leading to impaired flow of bile from the liver to the small intestine. While biliary duct obstruction can cause symptoms such as upper abdominal pain and vomiting, it is not typically associated with significantly elevated serum amylase and lipase levels.
D. While surgical site infection is a potential complication following cholecystectomy (gallbladder removal surgery), it typically presents with symptoms such as wound redness, swelling, warmth, and purulent drainage from the incision site.

A. An acutely distended bladder. B. Profuse forehead diaphoresis. C. Skeletal traction misalignment. D. A severe pounding headache.

Correct Answer is A

Explanation

A. One of the most common triggers is a distended bladder. When the bladder becomes full, it sends signals to the spinal cord, but due to the injury, these signals are unable to pass beyond the level of injury. This results in uncontrolled sympathetic activation, leading to symptoms such as hypertension, sweating, and headache.
B. Forehead diaphoresis, or sweating, is a potential symptom of autonomic dysreflexia. However, it is more of a consequence rather than a precipitating factor. It occurs as a result of sympathetic nervous system activation in response to the triggering stimulus.
C. Skeletal traction misalignment is not a common precipitating factor for autonomic dysreflexia. Autonomic dysreflexia is typically triggered by stimuli related to visceral or autonomic reflexes, such as bladder distention or bowel impaction, rather than mechanical issues like traction misalignment.
D. A severe pounding headache can occur as a symptom of autonomic dysreflexia, but it is not the primary precipitating factor. The headache is a result of the sudden increase in blood pressure that occurs during autonomic dysreflexia.

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While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

Correct Answer is A

Explanation

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