A patient is having a tonicclonic seizure. During the seizure, ...

[Lisaclaire]

A patient is having a tonicclonic seizure. During the seizure, the priority for nursing care is to
 
  1. protect the patient from injury.
  2. insert a bite block to prevent the patient from swallowing his or her tongue.
  3. ask the staff to hold the patient tightly.
  4. obtain vital signs.

Question 2

Following a fall, a patient is brought to the emergency department. There was a brief loss of consciousness. The patient complains of headache, has vomited twice, has a dilated pupil on the same side as a hematoma over the temporal area,
 
  and is currently having a seizure. What should the nurse anticipate regarding the care of this patient?
 
  1. This is an emergency situation that is likely due to an epidural hematoma and requires surgery.
  2. This is a controlled situation once the seizure stops.
  3. This is a serious situation in which a subdural hematoma is developing and requires surgery.
  4. This is a typical situation seen with most patients who fall and will subside with observation.

[lgoldst9]

Answer to Question 1

Correct Answer: 1
Because of the lack of warning with tonicclonic seizures, head injury, fractures, burns, or motor vehicle crashes may occur secondarily to seizure activity. A bite block is not needed and may injure the patient with forced insertion. The movements of the patient should not be restrained because this can cause injury. The vital signs cannot be measured during a tonicclonic seizure.

Answer to Question 2

Correct Answer: 1
Classic signs of an epidural hematoma include a loss of consciousness followed by a brief lucid period before rapid deterioration. Because this injury involves a skull fracture that tears an artery, the patient is bleeding uncontrollably into the head. Increased intracranial pressure and herniation will occur without prompt and timely intervention. A subdural hematoma would be manifested by drowsiness, confusion, and enlargement of the ipsilateral pupil within minutes of the injury. Hemiparesis and changes in respiratory pattern may soon follow. This patient will require immediate intervention and not simply observation.

[Lisaclaire]

TYSM

[ghepp]

Gracias!