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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A rising systolic blood pressure: While increased intracranial pressure can lead to changes in blood pressure, it is not typically the first sign observed. Changes in blood pressure may occur later in the progression of increased intracranial pressure.
B. Change in mood or attention level: Changes in mood, behavior, or level of consciousness are often early signs of increased intracranial pressure. These changes may include irritability, confusion, restlessness, or lethargy.
C. Irregular respiratory rate and depth: Respiratory changes such as irregular breathing patterns or Cheyne-Stokes respirations can occur with increased intracranial pressure, but they are not typically the first sign observed.
D. A bounding radial pulse: While changes in pulse rate or quality may occur with increased
intracranial pressure, a bounding radial pulse is not typically the first sign observed. It may occur later in the progression of increased intracranial pressure as compensation mechanisms fail.
Correct Answer is B
Explanation
A. Intracranial pressure: Monitoring intracranial pressure is important in clients with a history of subdural hematoma, but immediate assessment of respiratory status takes precedence in the immediate postoperative period to ensure adequate oxygenation and ventilation.
B. Respiratory status: Following evacuation of a subdural hematoma, the client may be at risk for respiratory compromise due to factors such as altered consciousness, impaired airway reflexes, or postoperative complications. Assessing respiratory rate, depth, oxygen saturation, and presence of respiratory distress is essential for early detection and intervention.
C. Temperature: Monitoring temperature is important for detecting signs of infection or systemic complications, but it is not the priority assessment immediately following evacuation of a subdural hematoma.
D. Serum electrolytes: While monitoring serum electrolytes is important for overall assessment and management of the client's condition, it is not the priority assessment in the immediate postoperative period following evacuation of a subdural hematoma.
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