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John Moore, a 22year-old patient who weighs 150 pounds, presents to the emergency deparbnent (ED) after being thrown front his horse and passing out...
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2. John Moore, a 22—year-old patient who weighs 150 pounds, presents to the emergency deparbnent (ED) after being thrown front his horse and passing out for a few minutes; heregained consciousness. The friend who was also riding a horse called the squad. The patient presented with a Glasgow IComa Scale {GCS} of 15, and the neurologic ezam waswithin normal limits ML). The EU physician wrote the orders for a CT scan without contrast of the head, CBC, renal and metabolic profile, PT, PTT, and Hill. The nurse sentthe labs and had the Pit of NS at keep-open rate per ED protocol hanging. The nurse was awaiting radiology to call for the patient to go for the ET when the patient had anepileptic cry, became unconscious, stiffened his entire body, and then had violent muscle contractions. The resp irations are very shallow, and the lips and nail bed became blue. The patient lost control of bladder and bowel. The patient bit his tongue and blood iscoming from the mouth. The radiology deparunent calls and is ready for the patient. {Learning Objectives Tr' and 3] a. List in the correct order the actions that should be taken by the nurse. b. Ezplain what type of seizure the patient is having, and describe the fl'll'EE phasesof the patient’s seizure and the specific nursing care for each stage. c. The ED physician orders the following: 1i.laliurn {diazepanr} 1E] mg every ill to 15minutes PEN for seizures (maximum dose of St] mg}. Once seizures stop, adrninister Dilantin (phenytoin) ll] nigflrg WPE. ECG monitoring continuously,vital signs, GCS, neurologic checlrs every 3t] minutes. Ezplain what medications the nurse should provide, in what order, and how they should be administered.