vSim Pediatrics | Jackson Weber (Neuro, Epilepsy)
Jackson experiences a generalized tonic clonic seizure while the nurse is caring for him. What with the highest priority and most appropriate nursing diagnosis at this time?
Impaired gas exchange relating to ineffective breathing pattern
A nurse is explaining to Jackson's mother how to respond when Jackson has a seizure at home. Which of the following statements by the mother indicates that teaching has been effective? Select all that apply
a. All toys and other hazards should be moved out of the way to keep Jackson safe b. Rolling Jackson to his side will help him breathe better and keep him from choking c. Someone should stay with Jackson until he fully wakes up after the seizure
A pt weighing 40 lb has an order for phenobarbital 60 mg BID. The safe dose range is 3-6 mg/kg/day. Is this order safe?
b) no. the safe range if 54.6-109.2 mg/day
A nurse is reviewing lab results and notes that a 5 y/o pt's serum phenobarbital level is 8. Phenobarbital is considered therapeutic at levels between 10-40. What is the nurse's best interpretation of this data?
d) Further assessment is needed regarding phenobarbital admin and compliance w/ therapy
The nurse is teaching Jackson's mother about went to seek emergency medical attention for Jackson in the event of seizure activity at home. Which response by Jackson mother indicates that further teaching is needed?
I need to call 911 every time Jackson has a seizure lasting longer than one minute.
The nurse is teaching Jackson's mother about phenobarbital and medication compliance. Which statement by Jackson's mother indicates that Teaching has been effective
Jackson needs to take the phenobarbital at the same time daily and have levels checked regularly
A nurse observes five-year-old Jackson experiencing a tonic clonic seizure. When documenting seizure activity, the nurse must include which of the following?
a. Length of seizure b. Characteristics and seizure c. Times seizure occurred
A nurse is caring for a preschool-aged pt experiencing generalized tonic-clonic seizures. This pt is at greatest risk for which of the following complications?
c) Aspiration d) Incontinence e) Head trauma Rationale: A child w/ altered LOC may not be able to manage his or her secretions and is at risk for aspiration and ineffective airway clearance. B/c of the loss of consciousness & rhythmic clonic contractions associated w/ this type of seizure, the pt is at risk for head trauma. Loss of sphincter control, leading to incontinence, is another complication associated w/ this type of seizure. Cardiac arrest and anaphylactic shock are not complications commonly associated w/ tonic-clonic seizures.
The nurse is tending to the stable patient who is in postictal phase following a generalized tonic clinic Seizure. What is the best position in which to place this patient
Right lateral
The role of the peds nurse has many components. Which of the following components includes the nurse's work with the interdisciplinary health care team to integrate the needs of the pt and family into a coordinated plan of care?
b) Collaborator
The nurses called to the bedside of a five-year-old patient experiencing a tonic clonic seizure. Upon arrival, seizure activity has seized. The patient is lethargic with shallow respirations at a rate of 12 breaths per minute and Oxygen saturation of 88%. The nurse can hear audible snoring sounds in the upper Airway and can see moderate secretions in the oral cavity. Place the following nursing interventions in order
1. Assess the patency of airway, breathing and circulation. 2. Manually open the airway as needed. 3. Suction the patient's mouth and nares. 4.Apply oxygen via face mask. 5. Place pt in side lying recovery position. 6. Monitor patient until level of consciousness returns to normal.
The nurse is evaluating a school-aged pt brought in for a recent decline in academic performance. The parent reports the pt has been doing poorly in school and states the child "wastes time staring at the wall and daydreaming instead of working." The nurse suspects that the pt may be experiencing which type of activity?
Absence Rationale: Absence seizures consist of sudden cessation of activity combined w/ a blank facial expression. This type od seizure lasts less than 30 secs and can occur multiple times during the day. B/c of the subtle changes in the pt behavior, absence seizure activity may not be recognized or may be perceived falsely as inattentiveness. Myoclonic seizures are characterized by sudden, brief, massive muscle jerks that may involve the whole body or one body part. Simple partial seizures are characterized by clonic or tonic movements involving the face, neck, and extremities and can include sensory signs such as numbness, tingling, paresthesia, or pain. Atonic seizures involve a sudden loss of muscle tone, which in children may be only a sudden drop of the head.
A pediatric patient experience a pro long time to clonic seizure lasting approximately five minutes seizure activity seized following administration of IV phenobarbital. 15 minutes later, the patient appears to be in a deep sleep and response only to people stimuli. Respirations are shallow at a rate of 16 breaths per minute with oxygen saturations of 90%. What is the most appropriate nursing action at this time
Apply oxygen 15 L per minute via a nonrebreather mask and continue to monitor
A nurse is teaching Jackson's mother about how management of epilepsy. Which statement by Jackson's mother indicates that teaching has been effective
Jackson needs to be supervised at all times when swimming
The nurse is admitting a peds pt w/ a known seizure hx w/ an order to implement seizure precautions. Which of the following interventions should the nurse include in the pt's plan of care?
a) Keep bed in low position and remove objects from the bed b) Supervise when ambulating or bathing d) Keep O2 and suction @ bedside Rationale: Basic seizure precautions should be implemented to provide a safe environment for the pt. The bed with everything removed and @ low position. O2 & suction available @ bedside. Supervision during bathing, ambulation, and other potentially unsafe activities helps to reduce the risk of an injury in the event that a seizure occurs. Although a ketogenicdiet is a nonpharmacologic tx for epilepsy, it wouldn't be appropriate for the nurse to implement this w/o an order from the provider. There is non need to insert a foley for a pt @ risk for seizures.
During an admission assessment, the nurse notes a sudden onset of tonic contractions of the pt's entire body followed by clonic contractions alternating w/ relaxation of all muscle groups. What actions should the nurse take?
b) Check for a patent airway c) Raise the side rails and remove any safety hazards Rationale: The nurse should ensure that the child has a patent airway and adequate oxygenation. The pt should be placed in a side-ting position, not supine, to help maintain a patent airway and decrease the risk for aspiration. Implementation of seizure precautions, including raising the side rails and removing any safety hazards, helps to keep the environment safe and reduce the risk of injury. Restraining the pt or placing anything in the mouth, such as a tongue blade, while the pt is actively seizing can cause further injury. The nurse should administer anticonvulsant meds as ordered to help stop and prevent further seizure activity, but administering PO meds during a seizure is not indicated d/t risk of aspiration.
The nurse is teaching the parent of a 5 y/o pt about home safety and injury prevention. Which of the following principles is correct regarding safety for this age group?
c) A forward-facing booster seat in the backseat w/ lap and shoulder belts should be used after reaching the car seat height restriction Rationale: After reaching the car seat height restriction, all 5 y/o should be in a booster seat that uses both the shoulder and lab belts. The backseat is the safest place for the child to ride. Forearms should be kept in a locked cabinet w/ the ammunition stored separately. Preschoolers are not mature enough to ride a bicycle in the street and should ride on the sidewalk; bicycles should be ridden in the same direction as traffic. To prevent accidental ingestion, parents would never describe meds as candy.