The nurse is observing a patient to determine if seizure activity is status epilepticus. For what length of time should seizure activity occur for this diagnosis to be appropriate for the patient?
a. 1 minute
b. 5 minutes
c. 20 minutes
d. 30 minutes
ANS: D
Status epilepticus is characterized by at least 30 minutes of repetitive seizure activity without a return to consciousness. This is a medical emergency and requires prompt intervention to prevent irreversible neurological damage. A. B. C. Seizure activity must occur for longer than 1, 5 or 20 minutes before being identified as status epilepticus.
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While auscultating heart sounds of a patient with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this as a:
A) First heart sound (S1) B) Third heart sound (S3) C) Fourth heart sound (S4) D) Murmur
Which symptom is commonly assessed when a patient has left ventricular heart failure?
a. Weight gain b. Swelling in the legs c. Jugular vein distention d. Crackles in the lungs
The nurse is educating a patient with a peripheral intravenous infusion of dextrose 5%. What is the most important information to share with the patient who has an IV infusing in the right hand?
A) Keep the IV fluids 18 inches above the extremity B) Caution the patient not to bend the right wrist C) Instruct on ambulating with an IV pole D) Instruct the patient on fluid volume excess
Only the nurse may use the patient plan of care
True False