A patient suddenly becomes unresponsive as you are speaking to him, and he develops trembling of all extremities. Your priority is to?

Appeared in: RAK Nursing Officer - 2019

Explanation

The highest priority in any emergency situation, including a seizure, is to follow the ABCs: Airway, Breathing, and Circulation.
During a seizure, a patient's muscle tone is altered, and they may lose the ability to protect their own airway.
The tongue can obstruct the pharynx, or the patient may aspirate on saliva or vomit, leading to life-threatening hypoxia or aspiration pneumonia.
Therefore, establishing and maintaining a patent airway is the most critical first step, taking precedence over all other actions.

Option A: Notifying the doctor is an important step, but it is not the immediate priority. Direct patient care to prevent life-threatening complications must come first.
Option B: Administering IV diazepam is a key treatment to stop a prolonged seizure (status epilepticus), but it is not the first priority. Airway management must precede medication administration.
Option D: A neurologic examination is an assessment, not an intervention. It cannot be performed while the patient is actively seizing and is not the priority.

Clinical Relevance

Nursing practice connection: Use the key finding related to Prioritization of nursing care during a seizure to guide bedside assessment, documentation, and the next nursing action.
In any clinical setting, a nurse's ability to rapidly apply the ABCs can be the difference between life and death. Seizures are a common neurological emergency.
Patient safety during a seizure includes not only airway management but also protecting the patient from physical injury by padding side rails and removing harmful objects.
What if? If the patient was sitting in a chair when the seizure began, the priority would be to safely guide them to the floor, then turn them onto their side to establish the airway, while protecting their head.

How to Approach the Question

First, identify the question as a 'priority' question. This means you must determine the most important action to take first.
Recognize the clinical event described: a sudden loss of consciousness with trembling, which is characteristic of a generalized seizure.
Apply the universal framework for emergencies: ABCs (Airway, Breathing, Circulation).
Evaluate each option based on the ABC framework. 'Establish an airway' directly addresses the 'A' and is the most immediate life-threatening risk during a seizure.
Eliminate the other options: Notifying the doctor and administering medication are secondary interventions. Performing an exam is an assessment, which is done after immediate life threats are managed.

Concept Tested & Keywords

Concept Tested: Prioritization of nursing care during a seizure
Stem keywords: unresponsive, trembling of all extremities, seizure, priority
Lead-in keywords: priority
Clinical cues: The patient's sudden unresponsiveness combined with trembling indicates an acute seizure, which is a medical emergency requiring immediate intervention.

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E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 pp. 23-25, 52-54

E6 Medicine Davidson Principles Practice 24e p. 215-217

Practise the full RAK Nursing Officer - 2019

Attempt every question from this paper in a timed mock, then review the full solution for each one.