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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Correct Answer is D

Explanation

A. Obtain the client's heart rate: While obtaining the client's heart rate is important in the assessment of autonomic dysreflexia, assessing for and addressing the underlying cause take precedence.

B. Administer a nitrate antihypertensive: Administering antihypertensive medication may be necessary if autonomic dysreflexia is confirmed, but it is not the first action to take. Addressing the cause of autonomic dysreflexia, such as bladder distention, is the priority.

C. Place the client in a high-Fowler's position: Elevating the client's head may help reduce blood pressure, but it does not address the underlying cause of autonomic dysreflexia. Assessing for and addressing the cause, such as bladder distention, is the priority.

D. Assess the client for bladder distention: Autonomic dysreflexia is commonly triggered by stimuli below the level of spinal cord injury, such as bladder distention. Assessing the client's bladder for distention and addressing any urinary retention or obstruction is the first action to take in managing autonomic dysreflexia.

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

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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

Correct Answer is B

Explanation

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