Which prescribed intervention will the nurse implement first for ...

[Hungry!]

Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing continuous tonic-clonic seizures?
 
  a. Give phenytoin (Dilantin) 100 mg IV.
  b. Monitor level of consciousness (LOC).
  c. Obtain computed tomography (CT) scan.
  d. Administer lorazepam (Ativan) 4 mg IV.

Question 2

The nurse observes a patient ambulating in the hospital hall when the patient's arms and legs suddenly jerk and the patient falls to the floor. The nurse will first
 
  a. assess the patient for a possible head injury.
  b. give the scheduled dose of divalproex (Depakote).
  c. document the timing and description of the seizure.
  d. notify the patient's health care provider about the seizure.

[bigcheese9]

Answer to Question 1

ANS: D
To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin will also be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.

Answer to Question 2

ANS: A
The patient who has had a myoclonic seizure and fall is at risk for head injury and should first be evaluated and treated for this possible complication. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications are also appropriate actions, but the initial action should be assessment for injury.

[Hungry!]

Thank you

[bigcheese9]

No problemo