You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to the LPN/LVN?

Correct Answer: D

Rationale: In the context of admitting a patient with a seizure disorder, delegating tasks appropriately is crucial for effective patient care. In this scenario, the correct answer is D) Pad the side rails before the patient arrives. This task can be safely delegated to the LPN/LVN because it is within their scope of practice and does not require advanced assessment skills. Padding the side rails helps prevent injury during a seizure by providing a soft surface in case the patient hits or thrashes against the rails. It is a proactive safety measure that can be done in advance of the patient's arrival without the need for immediate assessment or intervention. The other options are not suitable for delegation to the LPN/LVN in this situation. Completing the admission assessment (option A) requires thorough assessment skills and critical thinking abilities typically performed by the RN. Setting up oxygen and suction equipment (option B) involves ensuring proper functioning and appropriate settings, which are tasks best handled by a more experienced nurse. Placing a padded tongue blade at the bedside (option C) is not recommended as tongue blades are generally contraindicated during a seizure due to the risk of injury. This task also involves a level of judgment and decision-making that falls within the RN's scope of practice. By understanding the rationale behind delegating tasks based on scope of practice and patient safety, nursing students can develop the necessary skills to prioritize and assign responsibilities effectively in various clinical scenarios involving patients with neurological conditions like seizure disorders.

Correct Answer: A

Rationale: The correct answer is A) lie down in a safe place. When a person experiences an aura before a seizure, it serves as a warning sign that a seizure is imminent. Instructing the person to lie down in a safe place helps prevent injury during the seizure. Option B) take additional anticonvulsant medication is incorrect because taking medication during a seizure is not safe or effective. Anticonvulsant medications are prescribed to prevent seizures, not to be taken as needed during a seizure. Option C) call an ambulance is not necessary for every seizure, especially if the person is aware of their seizure pattern and can manage it safely. Option D) exercise vigorously is unsafe during a seizure and can increase the risk of injury. It is important to promote a safe environment and positioning during a seizure to prevent harm. In an educational context, it is crucial for nurses to understand seizure management to provide safe and effective care to patients. Teaching individuals with epilepsy about seizure precautions and appropriate responses helps empower them to manage their condition effectively. Nurses play a key role in educating patients and caregivers on seizure first aid, including the importance of lying down in a safe place during an aura to prevent injury.

Correct Answer: A

Rationale: The correct answer is A) Atropine sulfate. In the context of an edrophonium (Tensilon) test, which is used to diagnose myasthenia gravis, atropine sulfate must be available as an antidote. Edrophonium is a cholinesterase inhibitor that temporarily increases acetylcholine levels at the neuromuscular junction, potentially causing cholinergic crisis characterized by excessive muscarinic stimulation. Atropine sulfate, an anticholinergic agent, is used to counteract the muscarinic effects by blocking the action of acetylcholine at muscarinic receptors, effectively reversing the cholinergic crisis symptoms. The other options are incorrect because: - B) Diazepam (Valium) is a benzodiazepine used for its anxiolytic and anticonvulsant properties, not for reversing cholinergic crisis. - C) Ephedrine is a sympathomimetic amine that acts on adrenergic receptors, not muscarinic receptors like atropine sulfate. - D) Corticosteroids are anti-inflammatory agents that are not indicated for acute cholinergic crisis management. Understanding the appropriate antidotes and interventions for potential complications during diagnostic tests is crucial for nursing practice. Knowing the specific antidote needed for cholinergic crisis in the context of an edrophonium test is essential to ensure prompt and effective management of adverse reactions, thereby improving patient safety and outcomes.

Correct Answer: B

Rationale: The correct answer is B) Muscle spasms are beginning to occur. Joe's leg movement of pulling away during the bath indicates the onset of muscle spasms, which is a common neurological response post-injury. This can be attributed to the hyperexcitability of nerves in the injured area, leading to involuntary muscle contractions. It is crucial for the nurse to recognize this sign as it may indicate the need for interventions to manage the muscle spasms and prevent further complications such as contractures. Option A) He is embarrassed about having to be bathed is incorrect because the behavior described is more indicative of a physiological response rather than an emotional one. Option C) Paralysis is diminishing due to reduction in edema is incorrect because a reduction in paralysis due to decreased edema would not manifest as muscle spasms but rather as improved voluntary muscle movement. Option D) He is adjusting negatively to his disability is incorrect because the behavior described is not a result of psychological adjustment but rather a physiological response related to the neurological injury. In an educational context, understanding the significance of changes in muscle tone and movement post-neurological injury is essential for nurses caring for patients with such conditions. Recognizing early signs of muscle spasms can help in implementing appropriate interventions to prevent complications and promote optimal recovery.

Correct Answer: A

Rationale: Proper body alignment is crucial for hemiplegic patients to prevent complications like contractures. In this case, using a footboard helps maintain neutral ankle position, preventing plantar extension. Trochanter rolls aid in hip alignment, reducing internal hip rotation. Pillows support the affected side, preventing shoulder abduction. Choosing option A, plantar extension, as the correct answer is supported by the need to maintain proper foot alignment to prevent deformities. Plantar extension can lead to issues like foot drop and contractures, hence aligning the foot is essential. Option B, shoulder abduction, is incorrect as the question focuses on lower body alignment, not upper body positioning. Similarly, internal and external hip rotation (options C and D) are controlled by trochanter rolls, not footboard use. Educationally, understanding proper body alignment strategies for hemiplegic patients is vital for nursing practice. It promotes patient comfort, prevents complications, and supports overall rehabilitation efforts. Nurses must be knowledgeable about these interventions to provide holistic care and promote optimal patient outcomes.