RUHS, Jaipur, M.Sc Nursing Entrance Exam-2015
Medical Surgical Nursing
Medium
What will nurse do in case patient have seizures if alcohol is withdrawn suddenly?
Appeared in: RUHS, Jaipur, M.Sc Nursing Entrance Exam-2015
Explanation
- The highest priority in managing an active seizure is to protect the patient from physical injury.
- During a seizure, a person has no control over their movements and can be harmed by their surroundings or by aspiration.
- Key safety actions include clearing the area, protecting the head, and placing the patient in a side-lying (recovery) position to maintain a patent airway.
- Restraining a patient during a seizure is dangerous and can cause fractures or other serious injuries.
Why Other Options Were Wrong
- Option A: Restraining a patient during a seizure is contraindicated as it can cause severe musculoskeletal injury (e.g., fractures, dislocations) due to the force of the tonic-clonic contractions against the restraint.
- Option B: Drawing blood is a diagnostic measure, not a therapeutic or safety intervention. It is not the priority during an active seizure when the patient's life is at immediate risk from injury or airway compromise.
- Option C: While vital signs are important, it is impractical and secondary to attempt monitoring them during the violent muscle contractions of a seizure. The primary focus must be on immediate safety.
Related Visual
Clinical Relevance
- Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Nursing management of seizures, specifically those induced by alcohol withdrawal in acute care settings.
- Patient safety is the absolute priority in seizure management, aligning with the fundamental nursing principle of 'do no harm'.
- This scenario tests the nurse's ability to apply the ABCs (Airway, Breathing, Circulation) in an emergency. Turning the patient to the side directly protects the airway from aspiration.
- Alcohol withdrawal seizures ('rum fits') are a common and serious complication. They are typically generalized tonic-clonic and occur 6-48 hours after cessation of drinking. Prompt recognition and management are vital.
How to Approach the Question
- First, identify the core of the question: it asks for the priority nursing action during a seizure.
- Recognize this as a priority-setting question. In nursing, patient safety is almost always the highest priority.
- Evaluate each option based on the principle of safety. Ask yourself, 'Which of these actions will most directly protect the patient from immediate harm?'
- Option A (restrain) is actively harmful. Options B (blood sample) and C (vitals) are assessments that are secondary to immediate safety interventions.
- Option D (prevent injury) is a broad safety goal that encompasses all the correct immediate actions (e.g., protecting the head, clearing the area). Therefore, it is the best and most comprehensive answer.
Concept Tested & Keywords
- Concept Tested: Nursing management of seizures, specifically those induced by alcohol withdrawal.
- Stem keywords: seizures, alcohol withdrawal, nurse action
- Lead-in keywords: What will nurse do
- Clinical cues: The patient is having a seizure, which is a medical emergency requiring immediate safety interventions.
Question ID
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Reference Book
E6 Nursing Brunner Adult Health 3SA Vol 2 Part 3 p. 137-139
E6 Kaplan Sadock's Synopsis of Psychiatry-2022 (pp 1-3768 of 3768) p. 906-908
E6 Robert Boland, Marcia L. Verduin - Kaplan and Sadock's Comprehensive Text of Psychiatry-Wolters Kluwer Health (2024) (pp 1-16525 of 16525) p. 8848-8850
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