While assessing vital signs of a patient having recurrent attack of seizures the nurse should?

Appeared in: HPSSSB Staff Nurse - 2016

Explanation

All listed options are critical nursing assessments for a patient with recurrent seizures.
Seizures can cause hyperthermia, making temperature checks necessary. The axillary route is the safest to prevent biting injuries (SRC_13545).
While tachycardia is common, ictal bradycardia (slow heart rate) is a dangerous complication that must be monitored for.
Respiratory depression (bradypnea) or apnea can occur during or after a seizure, posing a risk for hypoxia and respiratory failure (SRC_13547).

Option A: This is a correct action, but it is not the only one. Focusing solely on temperature ignores critical cardiac and respiratory changes.
Option B: This is a correct observation, but it is incomplete. It overlooks equally important respiratory and temperature assessments.
Option C: This is a correct observation, but it is not comprehensive. Monitoring only respiration would miss potential hyperthermia and life-threatening cardiac arrhythmias.

Clinical Relevance

Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Vital sign monitoring in seizure patients in acute care settings.
Monitoring all vital signs in a patient with seizures is a fundamental nursing responsibility to ensure patient safety and detect life-threatening complications early.
Failure to observe for bradycardia can lead to a missed diagnosis of a serious cardiac issue related to epilepsy, increasing the risk of Sudden Unexpected Death in Epilepsy (SUDEP).
Nurses must be prepared to intervene immediately if bradypnea or apnea occurs, by positioning the patient, providing supplemental oxygen, and being ready for resuscitation.

How to Approach the Question

First, analyze the question stem to identify the core topic: nursing assessment during seizures.
Next, evaluate each option individually for its validity. Is taking an axillary temperature appropriate? Yes. Is observing for bradycardia important? Yes. Is observing for bradypnea necessary? Yes.
Recognize that seizures are a complex neurological event affecting multiple body systems (metabolic, cardiovascular, respiratory).
When you determine that multiple options are correct and an 'All of the above' option exists, it is highly likely to be the right answer.
Confirm this by considering if any of the individual options are more critical than the others. In this case, all are vital for a comprehensive assessment.
Therefore, select 'All of the above' as the most complete and correct answer.

Concept Tested & Keywords

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E6 Nursing Vital Signs p. 101-103

E6 Nelson Textbook of Pediatrics(2024) — Volume 1 p. 593-595

Practise the full HPSSSB Staff Nurse - 2016

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