John Moore, a 22-year-old patient weighing in at 150 pounds, arrived at the emergency department (ED) after being thrown from his horse and passing out for a few minutes; later he regained consciousness. The friend who was also riding a horse called the squad. The patient presented with a GCS of 15, and the neuro exam was within normal limits (WNL). The ED physician wrote the orders for a CT scan without contrast of the head, CBC, renal and metabolic profile, PT, PTT, and INR. The nurse sent the labs and had the IV of NS at keep-open rate per ED protocol hanging. The nurse was awaiting radiology to call for the patient to go for the CT when the patient had an epileptic cry, became unconscious, stiffened his entire body, and then had violent muscle contractions. His respirations were very shallow, and his lips and nail beds turned blue. The patient lost control of his bladder and bowel. The patient bit his tongue and was bleeding from his mouth. The radiology department called and was now ready for the patient.

Required:
a. List the correct order of actions that should be taken by the nurse.
b. Explain what type of seizure the patient is having, and describe the three phases of the patient’s seizure, and the specific nursing care for each stage.

Answer:

Explanation:

A) List in the correct order the actions that should be taken by the nurse.

Answer

Before and during a seizure, the patient is assessed and the following items are documented:

The circumstances before the seizure

The occurrence of aura

The first thing the patient does in the seizure – where movements or stiffness begins, conjugate gaze position, position of head

The type of movements in the part of the body involved

The areas of the body involved

The size of the pupils and whether the eyes are open

Whether the eyes or the head are turned to one side

The presence or absence of automatisms

Incontinence of urine or stool

Unconsciousness and its duration

Any obvious paralysis or weakness of arms or legs after the seizure

Inability to speak after the seizure

Movements at the end of the seizure

Whether or not the patient sleeps or not afterwards

Cognitive status after the seizure

In addition to providing data about the seizure, nursing care is directed at preventing injury and supporting the patient not only physically but also psychologically. Consequences such as anxiety, embarrassment, fatigue, and depression can be devastating to the patient.

After the patient has a seizure, the nurse’s role is to document the events leading to and occurring during and after the seizure to prevent complications.

2) Explain what type of seizure the patient is having, and describe the three phases of the patient’s seizure and the specific nursing care for each stage.

Answer

The patient had a tonic-clonic (gran mal) seizure. There are three phases namely the aura, the tonic and the clonic phase.

In the aura phase is the forewarning of an epileptic attack. It characterized by episodes of Déjà vu or Jamais vu. The client may also have auditory, olfactory, or even visual hallucinations, abnormal tastes, and tingling sensations. Physical symptoms include dizziness, headache, lightheadedness, nausea, numbness. Though in this case, the client did not show signs of the aura phase.

●Provide privacy and protect the patient from curious onlookers

Patients who have an aura may have time to seek a safe, private place

Ease the patient to the floor, if possible

Loosen constrictive clothing

Push aside any furniture that may injure the patient during a seizure

If an aura precedes the seizure, insert an oral airway to reduce the possibility of the patient’s biting the tongue

The next is the tonic phase. It is usually the shortest part of the seizure, lasting not more than only a few seconds. In this case, it is when the patient had an epileptic cry, became unconscious and stiffened his entire body.

●Protect the head with a pad to prevent injury from striking a hard surface

If the patient is in bed, remove pillows and raise side rails

The last is the clonic phase. It is when the client had violent muscle contractions, very shallow respirations, the lips and nail beds became blue, lost control of bladder and bowel and bit his tongue.

●Do not attempt to pry open jaws that are clenched in a spasm or to insert anything. Broken teeth and injury to the lips and tongue may result from such an action.

No attempt should be made to restrain the patient during the seizure because muscular contractions are strong and restraint can cause injury

If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use if necessary to clear secretions.

Which is a benefit of quitting smoking?

decreased allergic reactions
increased risk of high blood pressure
increased asthma problems
decreased risk of blood clot formation

Which of the following will most likely improve food-related choices at your
school?
A. Putting up anti-obesity posters
B. Offering multiple dessert choices
c. Offering healthful vending machine choices
D. Serving only processed food

what percentage of water is needed in human body​

Emus have better tactics than us. Change my mind.

Army I love u but I love jungkook more than u lol​

According to MyPlate, a balanced diet includes a blend of food from what
food groups?
A. Sugars, processed foods, dairy, grains, and vegetables
B. Fruits, vegetales, sugars, protein, and dairy
C. Fruits, vegetables, grains, protein, and dairy
D. Vegetables, meats, protein, dairy, and grains

Disease that can be passed from one person to another through PATHOGNS compatible disease or non-compatible disease

Tennis elbow happens to what percentage of the population, including
non-tennis players?
O 1%-3%
O 2%-10%
O 10%-20%
O 44%-5%

What can help control the spread of head lice?
following a well-balanced eating plan
frequently vacuuming at home
using curling irons or hot combs
frequently wearing hats

Which of the following positions used for venipuncture may cause harm to 5 points
the patient?
Patient sitting, phlebotomist sitting.
Patient sitting; phlebotomist standing.
Patient lying; phlebotomist standing.
Patient standing, phlebotomist standing.

New parents are often overwhelmed with the amount of information about feeding and care of infants.

a. True
b. Flase

Jeannine has no income and does not own a home. She has Alzheimer's and must receive care. How will Jeannine's long-term care be provided? Jeannine will go to a facility for the destitute and incompetent that is funded and run by her state government. Jeannine will need to go to live with her closest living relative. Medicare will cover long-term care once Jeannine's resources are used up. The money for care will be charged to Jeannine's estate, and her heirs will inherit a debt.

Write any two polite words?​

Nuva Ring?

Barrier
Hormone
Spermicide

An 85-year-old retired teacher comes to your office for evaluation of weakness. You obtain a complete history, perform a thorough physical examination, and order laboratory tests. You diagnose her with hyperthyroidism. Based on her age, which of the atypical symptoms of hyperthyroidism is more likely to be seen?

a. Fatigue
b. Weight loss
c. Tachycardia
d. Anorexia

Birth Control Pills and Condom
Barrier or hormone ?

Know what you need to do as a Freshman to prepare for your future, as well as what two classes you need to
pass in order to be classified as a Sophomore.

What is the difference between gender identity, sexual orientation, biological sex, and gender expression?

What is the RDA for pantothenic acid?

What colour are the blood cells that help fight infection?
Black
White
Blue
Red

Certain Infectious and Parasitic Diseases: Dermatophytosis of the foot. Enter code

Which assessment allows a trainer to understand a clients lean body and total fat mass?

Steve goes out with friends and eats a large breakfast. He doesn't want to
overeat, so he decides to skip lunch and dinner to make up for the amount of
food he consumed earlier. Is this a good plan?
A. Yes, because if he eats a full lunch and dinner, Steve will consume
too many calories during the course of the day.
O B. No, because if he skips meals, Steve will feel hungry later and
likely make poorer nutritional choices based on the immediate
need to find food.
C. Yes, because as long as he eats a large breakfast that can sustain
him throughout the day, Steve will not feel hungry later.
D. No, because he should really be eating five to six small meals a
day, so Steve should actually eat additional meals.

What are some barriers people face that prevent them from giving care?

2
Deductive reasoning involves moving from specific information to general information.
ОА.
True
OB
False

Please help and thank you. I Will give brainliest .

Answer fast please
Lucia has a very high-stress job that requires her to take on a lot of
responsibility. Which of the following would be a good stress-management
technique for Lucia to practice?
O A. Letting out her stress by yelling at people
ting
B. Getting regular exercise
O C. Quitting her job
D. Holding all of her stress in

Describe two types of barriers to exercise and provide at least two ways to overcome each type of barrier.

Do you feel ready to respond non-defensively if someone calls you out?

The nurse is caring for a client who has been
diagnosed with Cushing syndrome. Which
medication most likely contributed to this
condition?