While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?

Restrain the patient's arms and legs to prevent injury during the seizure.

Time and observe and record the details of the seizure and postictal state.

Insert an oral airway during the seizure to maintain a patent airway.

Avoid touching the patient to prevent further nervous system stimulation.

Answer and Explanation

The Correct Answer is B

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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Free Nursing Study Resources

Correct Answer is []

Explanation

The client is most likely experiencing meningitis based on the following clinical manifestations:

Symptoms: The client presents with a 2-day history of lethargy, nausea, vomiting, anorexia, headache, general muscle aches, diarrhea, abdominal pain, sore throat, sensitivity to light, and intermittent nystagmus. These symptoms are consistent with the classic signs of meningitis, including headache, nausea, vomiting, photophobia, and altered mental status.
Physical Examination Findings: The physical examination reveals a fever (temperature of 38.9°C or 102°F), elevated heart rate (118/min), and signs of meningeal irritation such as neck stiffness (not directly mentioned but implied by headache and sensitivity to light). Additionally, a pinpoint, red, macular rash on the upper chest may indicate petechiae, which can be seen in meningococcal meningitis.

Given the suspicion of meningitis, the nurse should take the following actions:

Implement seizure precautions: Meningitis can lead to increased intracranial pressure and neurological complications, including seizures. Implementing seizure precautions involves ensuring the client's safety by padding the side rails of the bed, keeping the bed in a low position, and providing close observation.
Dim the lights in the client’s room: The client reports sensitivity to light, which is a common symptom of meningitis due to meningeal irritation. Dimming the lights can help reduce discomfort and photophobia in the client.

Parameters to Monitor:

Neurologic status: Monitoring the client's neurologic status is crucial for assessing the progression of meningitis and detecting any neurological deterioration, such as changes in level of consciousness, motor deficits, or signs of increased intracranial pressure.
Temperature: Monitoring the client's temperature is essential to assess for fever spikes or trends, which can indicate the severity of the infection and response to treatment.

Persistent or worsening fever may suggest inadequate treatment or complications such as abscess formation.

A. Oriented to person, place, and year B. Severe headache C. Bradycardia D. Blurred vision

Correct Answer is B

Explanation

A. Oriented to person, place, and year: Meningitis often causes alterations in mental status, including confusion and disorientation. Therefore, the client may not be fully oriented to person, place, and time.

B. Severe headache: Headache is a hallmark symptom of meningitis and is often described as severe and persistent. It may be accompanied by other symptoms such as photophobia (sensitivity to light) and phonophobia (sensitivity to sound).

C. Bradycardia: Bradycardia is not typically associated with meningitis. In fact, tachycardia (elevated heart rate) may be present due to fever and systemic inflammation.

D. Blurred vision: While meningitis can lead to increased intracranial pressure, which may manifest as papilledema (swelling of the optic disc), blurred vision is not a common presenting symptom of meningitis. Visual changes are more commonly associated with conditions affecting the optic nerve or retina.

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While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion?

Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication?

The nurse in the emergency department is caring for a client who has fallen 20 feet from a roof. While performing the primary assessment, what is the most important nursing intervention?

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room? (Select all that apply.)

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

A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question?

When assessing the client with meningitis, the nurse looks for which manifestation as a frequent first sign of increased intracranial pressure?

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)