The nurse observes a novice nurse caring for a client experiencing status epilepticus. It will require immediate intervention if the novice nurse does which of the following?
A.
Activates the rapid response team (RRT).
B.
Loosens any restrictive clothing.
C.
Places the client in a lateral position.
D.
Prepares to administer intravenous valproate acid.
The Correct Answer and Explanation is:
The correct answer is D. Prepares to administer intravenous valproate acid.
Explanation:
Status epilepticus is a medical emergency characterized by prolonged or repeated seizures without full recovery of consciousness in between. It requires prompt and effective intervention to prevent brain damage, systemic complications, and potentially death. The management of a client experiencing status epilepticus follows specific protocols to ensure safety and provide appropriate care.
Why D is the correct answer:
Administering Intravenous Valproate Acid: While intravenous (IV) valproate acid can be used in the treatment of status epilepticus, it is not typically the first-line treatment in an emergency situation. The first-line treatment usually includes the administration of a benzodiazepine, such as lorazepam or diazepam, which acts rapidly to control seizures. Valproate is often considered when benzodiazepines and phenytoin/fosphenytoin are ineffective or contraindicated. The preparation to administer valproate acid indicates that the novice nurse may not be aware of the immediate need to administer the appropriate first-line treatment, which can delay the client’s care. Delaying appropriate treatment in status epilepticus can lead to worsening of the condition and serious complications.
Why the other options are not correct:
A. Activates the Rapid Response Team (RRT):
Activating the RRT is an appropriate action when a client is experiencing a severe medical emergency, such as status epilepticus. The RRT consists of healthcare professionals trained to respond rapidly to critical situations, ensuring the client receives immediate and specialized care.
B. Loosens Any Restrictive Clothing:
Loosening restrictive clothing is an appropriate intervention. It helps to ensure that the client can breathe freely and reduces the risk of injury during the seizure.
C. Places the Client in a Lateral Position:
Placing the client in a lateral (side-lying) position is a correct and critical action during a seizure. This position helps to prevent aspiration of saliva or vomit and keeps the airway open, reducing the risk of respiratory complications.
Conclusion:
In a status epilepticus situation, immediate and correct interventions are vital. The novice nurse’s preparation to administer IV valproate acid instead of a first-line treatment like benzodiazepines requires immediate intervention to prevent harm to the client and to ensure timely and effective management of the seizures.