Seizures
You are a high school nurse. A teacher is asking you about a student who occasionally stares blankly for 10 seconds during class and will resume conversation unaware anything happened. List the name of this seizure.
What is an absence seizure?
You have been floated to telemetry med-surg. One of the patients you are caring for has tested positive for Influenza A, the type more prone to causing widespread outbreaks. List the appropriate nursing interventions.
What is initiate droplet precautions and don a mask, gown, and gloves before entering?
A patient presents to the emergency department after a motor vehicle collision with sudden severe headache and decreasing level of consciousness. List what imaging study is most appropriate initially to assess for intracranial bleeding.
What is CT scan?
A 35-year-old male is admitted for right upper quadrant pain, nausea, and vomiting. Upon interview, he also reports pain in his right shoulder. List the two types of pain this patient is experiencing.
What is somatic and referred pain?
A 56-year-old patient is admitted after a head injury. You perform your routine neuro check and determine their vital signs are currently stable. List the first sign of increasing intracranial pressure.
What is change in level of consciousness?
You and your friend are both working on the unit today. He calls you for help with his patient that has been seizing for almost 2 minutes. List the first-line drug class to treat seizures and an example.
What are benzodiazepines and diazepam, lorazepam, or midazolam?
While charting at the nurses' station, you observe a new graduate nurse make a mistake when caring for a patient with Clostridiodes difficile. List at least 2 actions the new nurse may have performed incorrectly.
What is did not initiate contact precautions, did not don gown and gloves before entering patient room, used shared equipment without disinfecting between patients, and did not wash hands with soap and water?
You are on a 12-hour-shift with an AEMT-EMT team. A call comes in for a progressively confused 80-year-old male. Per wife, EMS learns he had a minor fall 3 days ago (positive head strike, on warfarin). List the type of hematoma the patient most likely has.
What is subdural hematoma?
A 68-year-old patient in the ICU presents with fever, hypotension, and acute confusion. The provider plans to start empiric antibiotic therapy immediately. List what nursing action must be taken before drug administration.
What is obtain blood cultures?
A patient is experiencing anaphylaxis after receiving a penicillin injection. List which branch of the nervous system is activated and at least 3 expected signs and symptoms.
What is sympathetic nervous system and tachycardia, hypotension (vasodilation), dyspnea/wheezing (bronchoconstriction), urticaria, flushing, angioedema, anxiety, restlessness?
Erika (MSN-Ed, RN) is teaching a class on seizure management. A nursing student asks her what nurses do after a seizure has stopped. List the name of this "post-seizure state" and priority actions the nurse should take.
What is postictal state and assess level of consciousness, oxygen saturation, and injuries?
You are in S2 at your Adult Health 2 clinical and have been assigned to IMU. Professor Harrell is pulling medications from the Pyxis for morning med pass. While reviewing patient charts, you notice a respiratory rule-out patient has tested positive for tuberculosis. List the appropriate nursing interventions.
What is initiate airborne precautions, place patient in negative pressure room, don N95 mask before entering, and have patient wear mask for patient transport outside of room?
You measure 550 cc after bladder scanning a 72-year-old male. You have performed straight catheterization twice this shift. The provider orders for a Foley catheter to be inserted. List at least 3 ways you might accidentally contaminate your sterile field.
What is sterile and non-sterile contact, reaching across sterile field, turning back on sterile field, holding sterile objects below the waist, within 1-inch border of sterile field, and wet surface under sterile set-up?
You are a critical care nurse caring for a patient with a Braden score of 12. List at least three appropriate nursing interventions.
What is perform regular skin assessments, reposition Q2H, use off-loading devices, consider specialty mattress, document photos/measurements as needed?
You are the triage nurse at a freestanding ER. A patient presents with acute stroke symptoms. List what BEFAST stands for and explain the rationale behind checking this patient's blood glucose level.
What is balance, eyes, face, arms, speech, time and hypoglycemia can mimic stroke symptoms?
A patient that is actively seizing has copious amounts of saliva in their airway. List appropriate nursing interventions to be performed during and after the seizure?
What is place patient in the recovery (side-lying, lateral) position and have suction ready to prevent aspiration?
You are reviewing the chart of your new admit and notice they have an absolute neutrophil count (ANC) of 500. List the appropriate nursing interventions and the rationale behind these actions?
What is initiate neutropenic precautions; perform hand hygiene and don mask before entering, and do not allow standing water, fresh flowers, and raw foods; the patient is immunosuppressed?
The provider has ordered an abdominal CT scan with contrast for a 34-year-old female. List all nursing actions that must be taken before imaging.
What is explain procedure to patient, ask about pregnancy status, ensure 18-20 gauge in AC, flush IV to test patency, assess for iodine/shellfish allergy, check renal labs (Cr/eGFR), remove metal, and have patient change into gown without buttons?
A patient recovering from surgery reports feeling unrefreshed despite sleeping all night. You know there is a stage of sleep most important for healing and tissue repair. List what stage of sleep this is and at least 3 patient teaching points to improve sleep hygiene.
What is NREM Stage 3 (deep sleep, delta waves) and avoiding caffeine and heavy meals before bed, keeping a consistent sleep schedule, minimizing environmental interruptions (e.g., bright lights, screen time, TV noise), and using relaxation techniques (e.g., deep breathing)?
You are rounding when you notice a patient who, at baseline, is alert and oriented, is now lethargic. Vitals: 68/40 BP, 49 MAP, 60 P, 97% RA. Neurologist at bedside provides a verbal order for a 500 cc bolus of 0.9% sodium chloride (NS). You place the patient into the Trendelenburg position. List the rationale behind this action and the priority nursing action.
What is a temporary increase in venous return and cardiac output and initiate fluid resuscitation?
A patient has been exhibiting tonic-clonic movements in bed for six minutes. List the condition name and at least 5 appropriate interventions.
What is protect airway, have oxygen & suction ready, turn the patient on their side, do not restrain or insert anything into the mouth, ensure IV access, and activate Rapid Response?
A septic patient has a blood pressure within their baseline range. Lactate is elevated and urine output is 20 mL/hr. List what this clinical presentation indicates.
What is inadequate tissue perfusion?
You are doing a routine admission on an 82-year-old postoperative patient with type 2 diabetes. You learn the patient is incontinent, has an indwelling Foley catheter, smokes one pack per day, and has poor appetite. List all reasons why this patient is at high risk for both infection and skin breakdown.
What is diabetes delaying wound healing, advanced age leading to thinner skin, surgery causing break in skin barrier, Foley catheter as portal for infection, poor nutrition affecting tissue repair, smoking reducing oxygen delivery, and incontinence causing maceration secondary to moisture?
A 72-year-old patient with long-standing hypertension and diabetes experiences a minor ischemic stroke. Imaging shows collateral flow through the Circle of Willis helping maintain perfusion. List the reason why the Circle of Willis is more effective at rerouting blood in this patient versus a healthy 25-year-old.
What is chronic vascular conditions gradually stimulating collateral circulation, strengthening the Circle of Willis' ability to compensate during cerebral ischemia?
A patient admitted for an ischemic stroke experiences hemorrhagic conversion. List what condition this will lead to and at least 3 appropriate nursing interventions.
What is increased intracranial pressure and ensure airway patency, perform regular neuro checks, elevate head of bed and keep head neutral midline, stabilize blood pressure, and avoid activities that increase ICP, such as coughing and straining?