Seizure Safety & Meds
A patient begins a tonic-clonic seizure in bed. Which positioning and injury-prevention actions should the nurse take?
Turn the patient onto the side, protect the head, and remove nearby objects. Rationale: The outline prioritizes airway protection and prevention of injury during seizures.
A patient suddenly develops facial drooping, arm weakness, and difficulty speaking. Which urgent action and time-related information should the nurse prioritize?
Activate the stroke response and determine when symptoms began. Rationale: BE-FAST emphasizes rapid recognition and emergency action; onset time guides time-sensitive treatment.
A patient with Parkinson’s disease has a shuffling gait and loses balance when turning. Which nursing intervention should be prioritized during ambulation?
Provide assistance with ambulation using a gait belt and implement fall precautions. Rationale: Postural instability, shuffling, and difficulty pivoting increase fall risk.
A patient with ALS has increasing weakness and difficulty clearing secretions. Which assessment takes priority?
Assess airway status and oxygen saturation. Rationale: Progressive respiratory muscle weakness places the patient at risk for respiratory failure.
A patient with Alzheimer’s disease becomes confused by a noisy, frequently changing environment. How should the nurse modify care?
Provide a calm, predictable environment, reduce stimuli, maintain the usual routine, and use memory cues. Rationale: These measures help the patient interpret surroundings and minimize confusion.
A patient says, "I have been seizure-free, so I will stop my anticonvulsant tonight." What teaching should the nurse provide?
Take the medication consistently as prescribed and never stop it abruptly. Rationale: Anticonvulsants control seizures but do not cure epilepsy; adherence helps prevent recurrence.
A patient with suspected acute stroke arrives in the ED. Which rapid imaging study should the nurse prepare the patient for before stroke-specific treatment?
A noncontrast head CT. Rationale: Rapid brain imaging distinguishes ischemic from hemorrhagic stroke and guides treatment.
A patient with Parkinson’s disease develops increased drooling and difficulty swallowing. Which assessment should the nurse prioritize?
Assess swallowing ability and aspiration risk. Rationale: Drooling can reflect difficulty swallowing saliva, and dysphagia increases aspiration and respiratory infection risk.
A patient with ALS is becoming immobile. Which interventions from the outline should the nurse include to reduce skin and mobility complications?
Reposition every 2 hours, assess skin, and provide range-of-motion exercises. Rationale: Immobility increases pressure injury risk, and ROM supports mobility management.
A patient with Alzheimer’s disease becomes agitated during bathing. What should the nurse do?
Remain calm, postpone the activity, and use distraction or a familiar calming approach such as music. Rationale: The outline recommends postponing activities during agitation and reducing excitement and confusion.
A patient taking phenytoin develops nystagmus, slurred speech, ataxia, and confusion. What should the nurse assess and report?
Assess for medication toxicity and report the findings; review the ordered phenytoin level. Rationale: These are toxicity findings listed in the outline, which gives a therapeutic range of 10–20.
An otherwise eligible patient with ischemic stroke has a BP of 192/114 mm Hg before IV alteplase. What should the nurse do before administration?
Report the BP and implement prescribed BP management before alteplase; verify BP is below 185/110 mm Hg. Rationale: The outline identifies this BP threshold before alteplase.
After a prescribed levodopa trial, a patient moves more easily and has less rigidity. How should the nurse evaluate the response?
Document improved movement and reduced symptoms as a positive response. Rationale: The outline identifies improvement with levodopa as supporting the clinical diagnosis and demonstrating treatment benefit.
A patient with ALS reports that swallowing has become more difficult. What should the nurse do?
Assess swallowing ability, elevate the head of the bed, and report the increased difficulty. Rationale: The outline emphasizes reporting worsening dysphagia because aspiration is a major complication.
A patient with Alzheimer’s disease wanders at night and is at risk for falling. Which environmental and behavioral interventions should the nurse use?
Remove hazards, provide adequate lighting or nightlights, secure doors appropriately, and use gentle persuasion and distraction. Rationale: The outline promotes safety and reduction of wandering while avoiding restraints.
A patient receiving valproate reports abdominal pain and unusual bruising. Which assessments and ordered laboratory results should the nurse prioritize?
Assess abdominal symptoms and bleeding; review liver enzymes, CBC, and platelet count and report abnormalities. Rationale: Valproate is associated with hepatotoxicity, pancreatitis, and thrombocytopenia.
A patient received alteplase 8 hours ago. Aspirin is now scheduled. What should the nurse do?
Withhold the aspirin and clarify the order before administration. Rationale: The outline specifies no anticoagulants or platelet inhibitors for the first 24 hours after alteplase because of bleeding risk.
An older patient taking benztropine develops urinary retention, constipation, and acute confusion. What should the nurse do?
Assess and report these anticholinergic effects for medication review. Rationale: The outline lists these adverse effects and notes that anticholinergics are used less often in older patients because of side effects.
A patient with ALS cannot speak clearly but remains cognitively intact. How should the nurse support participation in care?
Use communication strategies that allow the patient to express needs and choices, and provide emotional support. Rationale: The outline describes preserved cognition despite progressive motor impairment and emphasizes communication teaching.
A patient with Alzheimer’s disease can still dress with guidance, but the caregiver completes every task. What should the nurse teach?
Break dressing into short, achievable steps and encourage the patient to participate with needed supervision. Rationale: Simplifying tasks supports independence, dignity, and remaining function.
A convulsive seizure has lasted 5 minutes. IV lorazepam is prescribed. What emergency priorities and monitoring should the nurse implement?
Treat as status epilepticus: prioritize airway and safety, give IV lorazepam slowly as prescribed, and monitor respiratory rate, oxygen saturation, BP, and LOC with airway equipment ready. Rationale: Prolonged seizures threaten oxygenation, and lorazepam can cause respiratory depression and hypotension.
A lumbar puncture is planned for a patient with suspected subarachnoid hemorrhage, but increased ICP is identified. What is the nurse’s priority action?
Question the procedure and notify the provider before it proceeds. Rationale: The outline states that lumbar puncture should not be performed when increased ICP is present.
A patient on long-term carbidopa/levodopa develops head bobbing, grimacing, and rhythmic hand jerking. What should the nurse assess and report?
Assess and report dyskinesia and its impact on function and safety. Rationale: The outline associates these involuntary movements with long-term levodopa therapy.
During a neurologic assessment, a patient with brainstem involvement develops changes in breathing and cardiovascular status. Which nursing assessment should take priority?
Prioritize respiratory and cardiovascular assessment. Rationale: The brainstem contains centers that regulate respiration, blood pressure, and heart rate, so injury can threaten vital functions.
A patient with vascular dementia has hypertension and diabetes and suddenly becomes more inattentive than usual. Which assessment and ongoing teaching should the nurse prioritize?
Assess the acute change from baseline using the CAM features, including inattention, disorganized thinking, and altered LOC; reinforce management of hypertension and diabetes. Rationale: The outline includes CAM assessment and control of vascular conditions in dementia care.