The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?
Drug dependence
Cardiac rhythm
Pulse oximetry
Pain level
The Correct Answer is C
A. While drug dependence can be a concern with long-term use, it is not the immediate priority in an emergency setting where the goal is to stabilize the patient in status epilepticus.
B. Cardiac rhythm monitoring is important when administering certain medications, but lorazepam primarily affects the central nervous system and respiratory system, making oxygen saturation monitoring more critical.
C. Pulse oximetry is the priority assessment as IV lorazepam can depress the respiratory system, leading to hypoxia. Monitoring oxygen saturation helps ensure the patient maintains adequate respiratory function during administration.
D. Assessing pain is important in patient care, but it is not the priority in managing a patient in status epilepticus, where stabilization is essential.
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Correct Answer is A
Explanation
A. Neurogenic shock occurs in spinal cord injuries above T6 and is characterized by hypotension, bradycardia, and loss of sympathetic tone below the level of injury. This condition results from disruption of autonomic pathways.
B. Brain herniation typically involves increased intracranial pressure and different neurological symptoms.
C. Spinal shock involves temporary loss of reflexes and sensation but does not specifically cause bradycardia or hypotension.
D. Autonomic dysreflexia involves sudden high blood pressure and is usually triggered by noxious stimuli, occurring after the acute phase of SCI.
Correct Answer is A
Explanation
A. The fifth intercostal space at the left midclavicular line is the location of the mitral valve, where murmurs associated with mitral valve disease are best auscultated.
B. The fourth intercostal space at the right sternal border is the location for assessing the tricuspid valve, not the mitral valve.
C. The third intercostal space at the left midclavicular line is not associated with loudest auscultation of the mitral valve murmur.
D. The second intercostal space at the right sternal border is where the aortic valve sounds are best heard.