Exam 4 - third semester
The nurse is teaching a patient how to self-administer triptan injections for migraine headaches. Which statement by the patient indicates that he needs further teaching? a. "I will take this medication regularly to prevent a migraine headache from occurring." b. "I will take this medication when I feel a migraine headache starting." c. "This medication does not reduce the number of migraines I will have." d. "I will keep a journal to record the headaches I have and how the injections are working."
ANS: A Although they may be taken during aura symptoms by patients who have auras with their headaches, these drugs are not indicated for preventive migraine therapy. The medication is intended to relieve the migraine and not to prevent it or to reduce the number of attacks. The triptans do not reduce the number of migraines a person will have. Journal recordings of headaches and the patient's responses to the medication are helpful.
The child prescribed an antipsychotic medication to manage violent behavior is one most likely diagnosed with what disorder? a. attention deficit hyperactivity disorder (ADHD). b. posttraumatic stress disorder (PTSD). c. communication disorder. d. an anxiety disorder.
ANS: A Antipsychotic medication is useful for managing aggressive or violent behavior in some children diagnosed with ADHD. If medication were prescribed for a child with an anxiety disorder, it would be a benzodiazepine. Medications are generally not needed for children with communication disorder. Treatment of PTSD is more often associated with SSRI medications.
The nurse has given medication instructions to a patient receiving phenytoin (Dilantin). Which statement by the patient indicates that the patient has an adequate understanding of the instructions? a. "I will need to take extra care of my teeth and gums while on this medication." b. "I can go out for a beer while on this medication." c. "I can skip doses if the side effects bother me." d. "I will be able to stop taking this drug once the seizures stop."
ANS: A Scrupulous dental care is necessary to prevent gingival hypertrophy during therapy with phenytoin. Alcohol and other central nervous system depressants may cause severe sedation. Consistent dosing is important to maintain therapeutic drug levels. Therapy with AEDs usually must continue for life and must not be stopped once seizures stop.
A patient is taking Phenytoin for treatment of seizures. Which statement by the patient requires you to re-educate the patient about this medication? A. "Every morning I take this medication with a full glass of milk with my breakfast." B. "I know it is important to have my drug levels checked regularly." C. "I will report a skin rash immediately to my doctor." D. "This medication can lower my body's ability to clot and fight infection."
ANS: A This medication should NOT be taken with milk products or antacids because it affects absorption. All the other options are correct.
The nurse is caring for a client who has severe hypoglycemia and is experiencing a seizure. What actions will the nurse take at this time? (Select all that apply.) a. Administer glucagon 1 mg subcutaneously. b. Be sure the bed side rails are in the up position. c. Notify the primary health care provider immediately. d. Monitor the client's blood glucose level. e. Increase the intravenous infusion rate immediately.
ANS: A, B, C, D The client who has severe hypoglycemia often has a blood sugar of less than 20 mg/dL (1.0 mmol/L) and may be unconscious or seizing. Therefore, the client cannot swallow and needs glucagon. To keep the client safe during the seizure, the nurse ensures that the side rails are up to prevent the client from falling out of bed. The nurse would also monitor the client's blood sugar to evaluate the effectiveness of the interventions.
A nurse is teaching a client who experiences migraine headaches and is prescribed propranolol. Which statement would the nurse include in this client's teaching? a. "Take this drug only when you have symptoms indicating the onset of a migraine headache." b. "Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches." c. "This drug will relieve the pain during the aura phase soon after a headache has started." d. "This drug will have no effect on your heart rate or blood pressure because you are taking it for migraines."
ANS: B Propranolol is a beta-adrenergic blocker which is prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client would monitor these side effects. The other responses do not discuss appropriate uses of this drug.
A kindergartener is disruptive in class. This child is unable to sit for expected lengths of time, inattentive to the teacher, screams while the teacher is talking, and is aggressive toward other children. The nurse plans interventions designed to achieve what? a. integration of self-concept. b. inpatient treatment for the child. c. loneliness and increase self-esteem. d. language and communication skills.
ANS: C Because of their disruptive behaviors, children diagnosed with attention deficit hyperactivity disorder (ADHD) often receive negative feedback from parents, teachers, and peers, leading to self-esteem disturbance. These behaviors also cause peers to avoid the child with ADHD, leaving the child with ADHD vulnerable to loneliness. The child does not need inpatient treatment at this time. The incorrect options might or might not be relevant.
A nurse will prepare teaching materials for the parents of a child newly diagnosed with attention deficit hyperactivity disorder (ADHD). Information will focus on which medication likely to be prescribed? a. Paroxetine b. Imipramine c. Methylphenidate d. Carbamazepine
ANS: C Central nervous system (CNS) stimulants are the drugs of choice for treating children diagnosed with ADHD. Methylphenidate and mixed amphetamine salts are most commonly used. None of the other drugs are psychostimulants used to treat ADHD.
The nurse is preparing to teach a client recently diagnosed with multiple sclerosis about taking glatiramer acetate. Which statement by the client indicates a need for further teaching? a. "I will rotate injection sites to prevent skin irritation." b. "I need to avoid large crowds and people with infection." c. "I should report any flulike symptoms to my primary health care provider." d. "I will report any signs of infection to my primary health care provider."
ANS: C Glatiramer is given by subcutaneous injection. The first dose is administered under medical supervision, but the nurse teaches the client how to self-administer the medication after the initial dose, reminding the client about the need to rotate injection sites. Like other immunomodulators, this drug can make the client susceptible to infection. However, flulike symptoms occur more commonly with interferons rather than glatiramer.
Which behavior indicates that the treatment plan for a child diagnosed with an autism spectrum disorder was effective? a. plays with one toy for 30 minutes. b. repeats words spoken by a parent. c. holds the parent's hand while walking. d. spins around and claps hands while walking.
ANS: C Holding the hand of another person suggests relatedness. Usually, a child diagnosed with an autism spectrum disorder would resist holding someone's hand and stand or walk alone, perhaps flapping arms or moving in a stereotyped pattern. The incorrect options reflect behaviors that are consistent with autism spectrum disorders.
The nurse is caring for a client who is diagnosed with a complete small bowel obstruction. For what priority problem is this client most likely at risk? a. Abdominal distention b. Nausea c. Electrolyte imbalance d. Obstipation
ANS: C The client who has a small bowel obstruction is at the highest risk for fluid and electrolyte imbalances, especially dehydration and hypokalemia due to profuse vomiting. Nausea, abdominal distention, and obstipation are also usually present, but these problems are not as life threatening as the imbalances in electrolytes.
A child diagnosed with attention deficit hyperactivity disorder (ADHD) shows hyperactivity, aggression, and impaired play. the health care provider prescribed amphetamine salts. the nurse should monitor for which desired behavior? a. Increased expressiveness in communication with others b. Abilities to identify anxiety and implement self-control strategies c. Improved abilities to participate in cooperative play with other children d. Tolerates social interactions for short periods without disruption or frustration
ANS: C The goal is improvement in the child's hyperactivity, aggression, and play, the remaining options are more relevant for a child with intellectual development disorder or an anxiety disorder.
The nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. What action would the nurse take first? a. Start fluids via a large-bore catheter. b. Administer IV push diazepam. c. Turn the client's head to the side. d. Prepare to intubate the client.
ANS: C The nurse would turn the client's head to the side to prevent aspiration and allow drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the seizure is sustained (status epilepticus), the client must be intubated and would be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or diazepam.
Your patient has a history of epilepsy. While helping the patient to the restroom, the patient reports having this feeling of déjà vu and seeing spots in their visual field. Your next nursing action is to? A. Continue assisting the patient to the restroom and let them sit down. B. Initiate the emergency response system. C. Lay the patient down on their side with a pillow underneath the head. D. Assess the patient's medication history.
ANS: C The patient is reporting signs and symptoms of an aura (this is a warning sign before a seizure event). Lay the patient down on their side with a pillow underneath the head and remove any restrictive clothing. Also, time the seizure. If the seizure lasts more than 5 minutes or if the patient starts to have seizures back-to-back activate the emergency response system.
A nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is most associated with the child's disorder? a. has occasional toileting accidents. b. interrupts or intrudes on others. c. cries when separated from a parent. d. continuously rocks in place for 30 minutes.
ANS: D Autism spectrum disorder involves distortions in development of social skills and language that include perception, motor movement, attention, and reality testing. Body rocking for extended periods suggests autism spectrum disorder. Occasional toileting accidents and crying when separated from a parents are expected findings for a 3-year-old. Interrupting or intruding on others are assessment findings associated with ADHD.
The nurse is caring for a client with a large bowel obstruction due to fecal impaction. What position would be appropriate for the client while in bed? a. Prone b. Supine c. Recumbent d. Semi-Fowler
ANS: D Having the client in a semi-sitting position helps to decrease the pressure caused by abdominal distention and promotes thoracic expansion to facilitate breathing.
A child diagnosed with attention deficit hyperactivity disorder (ADHD) had this nursing diagnosis: impaired social interaction related to excessive neuronal activity as evidenced by aggression and demanding behavior with others. Which finding indicates the plan of care was effective? a. has an improved ability to identify anxiety and use self-control strategies b. has increased expressiveness in communication with others. c. shows increased responsiveness to authority figures. d. engages in cooperative play with other children.
ANS: D The goal should be directly related to the defining characteristics of the nursing diagnosis, in this case, improvement in the child's aggressiveness and play. The distracters are more relevant for a child with autism spectrum or anxiety disorder.
A patient is admitted with ulcerative colitis. In the physician's notes, it is stated that the patient's barium enema results showed the patient has colitis that starts in the rectum and extends into the sigmoid and descending colon. As the nurse, you know that this is what type of ulcerative colitis? A. Right-sided colitis B. Proctosigmoiditis C. Ulcerative procotitis D. Left-sided colitis
ANS: D. Left-sided colitis (distal colitis) starts in the rectum and goes to the sigmoid and descending colon. Ulcerative proctitis affects the rectum only. Proctosigmoiditis affects the rectum and sigmoid colon. Right-sided colitis is NOT a type of ulcerative colitis.
True or False: NSAIDs are used as first-line treatment for pain relief with patients with ulcerative colitis. True False
FALSE. NSAIDs should be avoided in patients with ulcerative colitis because they can cause a "flare-up" in the condition. Tylenol should be used instead or a similar medication that isn't an NSAID.
True or False: A patient who is experiencing a tonic-clonic seizure is experiencing a focal (partial) seizure. True False
FALSE: A patient who is experiencing a tonic-clonic seizure is experiencing a GENERLAIZED seizure. This type of seizure affects both sides of the brain.
A child diagnosed with attention deficit hyperactivity disorder (ADHD) will begin medication therapy. the nurse should prepare a plan to teach the family about which classification of medications? a. CNS stimulants b. Tricyclic antidepressants c. Antipsychotics d. Anxiolytics
ANS: A CNS stimulants, such as methylphenidate and pemoline, increase blood flow to the brain and have proved helpful in reducing hyperactivity in children and adolescents with ADHD. the other medication categories listed would not be appropriate.
The nurse assesses clients on a medical-surgical unit. Which clients would the nurse identify as at risk for secondary seizures? (Select all that apply.) a. A 26-year-old woman with a left temporal brain tumor b. A 38-year-old male client in an alcohol withdrawal program c. A 42-year-old football player with a traumatic brain injury d. A 66-year-old female client with multiple sclerosis e. A 72-year-old man with chronic obstructive pulmonary disease
ANS: A, B, C Clients at risk for secondary seizures include those with a brain lesion from a tumor or trauma, and those who are experiencing a metabolic disorder, acute alcohol withdrawal, electrolyte disturbances, and high fever. Clients with a history of stroke, heart disease, and substance abuse are also at risk. Clients with multiple sclerosis or chronic obstructive pulmonary disease are not at risk for secondary seizures.
A patient is suspected of having multiple sclerosis. The neurologist orders various test. The patient's MRI results are back and show lesions on the cerebellum and optic nerve. What signs and symptoms below would correlate with this MRI finding in a patient with multiple sclerosis? (select all that apply) A. Blurry vision B. Pain when moving eyes C. Dysarthria D. Balance and coordination issues E. "Pill rolling" of fingers and hands G. Heat intolerance H. Dark spots in vision I. Ptosis
ANS: A, B, C, D, H If lesions are present on the optic nerves, optic neuritis can occurs which can lead to blurry vision, pain when moving the eyes, and dark spots in the vision. If cerebellar lesions are found, this can affect movement, speech, and some cognitive abilities. This would present as dysarthria (issues articulating words), and balance/coordination issues. "Pill rolling" of the fingers and hands is found in Parkinson's disease. Ptosis is common in myasthenia gravis, and heat intolerance in thyroid issues.
The nurse is reviewing herbal therapies. Which is a common use of the herb feverfew? a. Muscle aches b. Migraine headaches c. Leg cramps d. Incision pain after surgery
ANS: B Feverfew is commonly used for migraine headaches, menstrual problems, arthritis, and fever. Possible adverse effects include muscle stiffness and muscle and joint pain.
You have a patient who has a brain tumor and is at risk for seizures. In the patient's plan of care you incorporate seizure precautions. Select below all the proper steps to take in initiating seizure precautions: A. Oxygen and suction at bedside B. Bed in highest position C. Remove all pillows from the patient's head D. Have restraints on stand-by E. Padded bed rails F. Remove restrictive objects or clothing from patient's body G. IV access
ANS: A, E, F, G The bed needs to be in the LOWEST position possible, a pillow should be underneath the patient's head to protect it from injury, AVOID using restraints (this can cause musculoskeletal damage).
The nurse is ordered to administer Lorazepam to a patient experiencing status epilepticus. As a precautionary measure, the nurse will also have what reversal agent on standby? A. Narcan B. Flumazenil C. Calcium Chloride D. Idarucizumab
ANS: B Flumazenil is the reversal agent for Lorazepam, which is a benzodiazepine.
A patient with multiple sclerosis has issues with completely emptying the bladder. The physician orders the patient to take ___________, which will help with bladder emptying. A. Bethanechol B. Oxybutynin C. Avonex D. Amantadine
ANS: A. This medication is a cholinergic medication that will help with bladder emptying.
Which finding below represents a positive Romberg Sign in a patient with multiple sclerosis? A. The patient report dark spots in the visual fields during the confrontation visual field test. B. When the patient closes the eyes and stands with their feet together they start to lose their balance and sway back and forth. C. The patient's sign and symptoms increase when expose to hot temperatures. D. The patient reports an electric shock feeling when the head and neck are moved downward.
ANS: B
During your discharge teaching to a patient with multiple sclerosis, you educate the patient on how to avoid increasing symptoms and relapses. You tell the patient to avoid: A. Cold temperatures B. Infection C. Overexertion D. Salt F. Stress
ANS: B, C, F. The patient should also avoid extreme heat, which can increase symptoms.
Select all the TRUE statements about the pathophysiology of multiple sclerosis: (SATA) A. "The dendrites on the neuron are overstimulated leading to the destruction of the axon." B. "The myelin sheath, which is made up of Schwann cells, is damaged along the axon." C. "This disease affects the insulating structure found on the neuron in the central nervous system." D. "The dopaminergic neurons in the part of the brain called substantia nigra have started to die."
ANS: B, C. In multiple sclerosis the myelin sheath (which is the insulating and protective structure made up of Schwann cells that protects the axon) is damaged. MS affects the CNS (central nervous system) and when the myelin sheath becomes damaged it leads to a decrease in nerve transmission.
You're patient is scheduled for an EEG (electroencephalogram). As the nurse you will: (SATA) A. Keep the patient nothing by mouth. B. Hold seizure medications until after the test. C. Allow the patient to have coffee, milk, and juice only. D. Wash the patient's hair prior to the test. E. Administer a sedative prior to the test.
ANS: B, D An EEG is a painless procedure that will assess the patient's brain activity (if a seizure occurs during the test this can allow the physician to determine what type of seizure it is). Therefore, the nurse would hold seizure medications (this can affect the test) and would NOT allow the patient to have caffeine like coffee or stimulant drugs (the patient can eat prior to the test just NO caffeine). The patient's hair should be cleaned prior to the test so the technician can apply the electrodes and get them to stick to the scalp easily. A sedative is not needed before this test.
You're educating a group of outpatients about signs and symptoms of ulcerative colitis. Which of the following are NOT typical signs and symptoms of ulcerative colitis? SELECT-ALL-THAT-APPLY: A. Rectal Bleeding B. Abdominal mass C. Bloody diarrhea D. Fistulae E. Extreme Hungry F. Anemia
ANS: B, D, E. Rectal bleeding, bloody diarrhea, and anemia are present in ulcerative colitis. However, an abdominal mass or fistulae tends to be present with Crohn's Disease. Loss of appetite rather than extreme hungry presents in ulcerative colitis.
Which medications below can help treat muscle spasms in a patient with multiple sclerosis? Select all that apply: A. Propranolol B. Isoniazid C. Baclofen D. Diazepam E. Modafinil
ANS: C, D
A patient is receiving treatment for ulcerative colitis by taking Azathioprine. Which physician's order would the nurse question if received? A. Ambulate the patient twice day B. Low-fiber and high-protein diet C. Administer varicella vaccine intramuscularly D. Administer calcium carbonate by mouth daily
ANS: C. Azathioprine is an immunosuppression medication that decreases the immune system. Therefore, the patient should never receive a live vaccine, such as Varicella. Other vaccinations that are live include: MMR, Shingles, Nasal influenza mist etc.
A patient is receiving Interferon Beta for treatment of multiple sclerosis. As the nurse you will stress the importance of? A. Physical exercise to improve fatigue B. Low fat diet C. Hand hygiene and avoiding infection D. Reporting ideation of suicide
ANS: C. Interferon Beta decreases the number of relapses of symptoms in MS patients by decreasing the immune system response, but it lowers the white blood cells count. Hence, there is a risk of infection. It is very important the nurse stresses the importance of hand hygiene and avoiding infection.
The parent of a 6-year-old says, "My child is in constant motion and talks all the time. My child isn't interested in toys but is out of bed every morning before me." The child's behavior is most consistent with diagnostic criteria for which disorder? a. communication disorder. b. stereotypic movement disorder. c. intellectual development disorder. d. attention deficit hyperactivity disorder (ADHD).
ANS: D Excessive motion, distractibility, and excessive talkativeness are seen in ADHD. The behaviors presented in the scenario do not suggest intellectual development, stereotypic, or communication disorder.
A patient diagnosed with pancolitis is experiencing extreme abdominal distension, pain 10 on 1-10 scale in the abdomen, temperature of 103.6 'F, HR 120, and profuse diarrhea. What complication due you suspect the pain is experiencing? A. Fistulae B. Stricture C. Bowel obstruction D. Toxic megacolon
ANS:D. Pancolitis affects all the colon and is a very severe form of ulcerative colon. The patient is at risk for toxic megacolon. In toxic megacolon, the large intestine dilates due to the overwhelming inflammation. The large intestine is unable to function properly and becomes paralyzed. Typical signs and symptoms of toxic megacolon include: abdominal distention, fever, diarrhea, abdominal pain, dehydration, and tachycardia.
True or False: Ulcerative colitis is a type of inflammatory bowel disease that causes inflammation and ulcer formation in the inner lining of the small intestine, specifically the terminal ileum. True False
FALSE: Ulcerative colitis is a type of inflammatory bowel disease that causes inflammation and ulcer formation in the inner lining of the LARGE (not small) intestine. The inflammation tends to start in the rectum and spreads throughout the colon. The small intestine is usually not involved.
True or False: Multiple Sclerosis tends to affect men more than women and occurs during the ages of 50-70 years. True False
False: MS affects WOMEN more than men and shows up during the ages of 20-40 years.
True or False: Patients with multiple sclerosis have different signs and symptoms because this disease can affect various areas of the peripheral nervous system. True False
False: Yes, patients with MS have different signs and symptoms because lesions can present at different locations in the CENTRAL NERVOUS SYSTEM....hence the brain and spinal cord (not the peripheral nervous system).
Which nursing diagnosis is universally applicable for children diagnosed with autism spectrum disorders? a. Impaired social interaction related to difficulty maintaining relationships b. Chronic low self-esteem related to excessive negative feedback c. Deficient fluid volume related to abnormal eating habits d. Anxiety related to nightmares and repetitive activities
ANS: A Children diagnosed with autism spectrum disorders display profoundly disturbed social relatedness. They seem aloof and indifferent to others, often preferring inanimate objects to human interaction. Language is often delayed and deviant, further complicating relationship issues. The other nursing diagnoses might not be appropriate in all cases.
A nurse is caring for a client who has been diagnosed with a small bowel obstruction. Which assessment findings would the nurse correlate with this diagnosis? (Select all that apply.) a. Serum potassium of 2.8 b. Loss of 15 lb (6.8 kg) without dieting c. Abdominal pain in upper quadrants d. Low-pitched bowel sounds e. Serum sodium of 121
ANS: A, C, E Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range is 3.5 to 5.0) and hyponatremic (normal range is 136 to 145). Abdominal pain across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be noted with small bowel obstructions.
A client has a brain tumor and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying that the client does not have a seizure disorder. What response by the nurse is correct? a. "Increased pressure from the tumor can cause seizures." b. "Preventing febrile seizures with a tumor is important." c. "Seizures always occur in clients with brain tumors." d. "This drug is used to sedate with a brain tumor."
ANS: A Brain tumors can lead to seizures as a complication. The nurse would explain this to the spouse. Preventing febrile seizures is not related to a tumor. Seizures are possible but do not always occur in clients with brain tumors. This drug is not used for sedation.
A client who has multiple sclerosis reports increased severe muscle spasticity and tremors. What nursing action is most appropriate to manage this client's concern? a. Request a prescription for an antispasmodic drug such as baclofen. b. Prepare the client for deep brain stimulation surgery. c. Refer the client to a massage therapist to relax the muscles. d. Consult with the occupational therapist for self-care assistance.
ANS: A Clients who have multiple sclerosis often have muscle spasticity which may be reduced by drug therapy, such as baclofen. While massage and assistance with self-care may be helpful, these interventions are not the most effective and therefore not the most appropriate in managing muscle spasticity. If drug therapy and other interventions do not help reduce muscle spasms, some client are candidates for deep brain stimulation as a last resort.
You're assessing a patient who recently experienced a focal type seizure (partial seizure). As the nurse, you know that which statement by the patient indicates the patient may have experienced a focal impaired awareness (complex partial) seizure? A. "My friend reported that during the seizure I was staring off and rubbing my hands together, but I don't remember doing this." B. "I remember having vision changes, but it didn't last long." C. "I woke up on the floor with my mouth bleeding." D. "After the seizure I was very sleepy, and I had a headache for several hours."
ANS: A The patient will experience an alternation in consciousness (hence the name focal IMPAIRED awareness) AND will perform an action without knowing they are doing it called automatism like lip-smacking, rubbing the hands together etc. With a focal onset AWARE seizure (also called partial simple seizure) the patient is aware and will remember what happens (like vision changes etc.).
The nurse is caring for a client experiencing upper gastrointestinal (GI) bleeding. What is the priority action for the client's care? a. Maintain airway, breathing, and circulation. b. Monitor vital signs, including orthostatic blood pressures. c. Draw blood for hemoglobin and hematocrit immediately. d. Insert a nasogastric (NG) tube and connect to intermittent suction.
ANS: A The priority action for any client experiencing deterioration or an emergent situation is monitor and maintain airway, breathing, and circulation (ABCs). Taking orthostatic blood pressures would not be appropriate, but the nurse would monitor vital signs carefully and draw blood for hemoglobin and hematocrit. An NG tube would also need to be inserted and connected to gastric suction to rest the GI tract. However, none of these actions take priority over maintaining ABCs.
The nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding—erosion of the bowel wall b. Abscess formation—localized pockets of infection develop in the ulcerated bowel lining c. Toxic megacolon—transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction—paralysis of colon resulting from colorectal cancer e. Fistula—dilation and colonic ileus caused by paralysis of the colon
ANS: A, B, D Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon.
The nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding—erosion of the bowel wall b. Abscess formation—localized pockets of infection develop in the ulcerated bowel lining c. Toxic megacolon—transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction—paralysis of colon resulting from colorectal cancer e. Fistula—dilation and colonic ileus caused by paralysis of the colon
ANS: A, B, D Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon.
You're providing diet teaching to a patient with ulcerative colitis about what types of foods to avoid during a "flare-up". Which foods below should the patient avoid? SELECT-ALL-THAT-APPLY: A. Ice cream B. White Rice C. Fresh apples and pears D. Popcorn E. Cooked carrots
ANS: A, C, D. Patients experiencing a flare-up with ulcerative colitis should avoid dairy products (ice cream), food that are high in fiber (fresh apples or pears) (cooked fruits without the skin would be okay), and foods that are hard to digest (popcorn). Instead, patients should consume foods low in fiber (low residue) like cooked vegetables (carrots), bland foods (white rice) etc.
You're assessing your patient load for the patients who are at MOST risk for seizures. Select all the patients below that are at risk: A. A 32-year-old with a blood glucose of 20 mg/dL. B. A 63-year-old whose CT scan shows an ischemic stroke. C. A 72-year-old who is post opt day 5 from open heart surgery. D. A 16-year-old with bacterial meningitis. E. A 58-year-old experiencing ETOH withdrawal.
ANS: A, B, D, E All the patients are at risk except option C. Remember all the risk factors: illness (especially CNS types like bacterial meningitis), fever, electrolyte/metabolic issues (low blood sugar, acidosis etc), ETOH (alcohol) withdraw, brain injury, STROKE, congenital brain defects, tumors etc.
The nurse assesses a client who is experiencing a common migraine without an aura. Which assessment finding(s) would the nurse expect? (Select all that apply.) a. Headache lasting up to 72 hours b. Unilateral and pulsating headache c. Abrupt loss of consciousness d. Acute confusion e. Pain worsens with physical activities f. Photophobia
ANS: A, B, E, F A common migraine with an aura is usually accompanied by photophobia, phonophobia, unilateral and pulsating pain, and nausea and/or vomiting. These migraines usually last 4 to 72 hours and are aggravated by physical activity. Loss of consciousness and acute confusion are not associated with a common migraine without an aura.
A nurse assesses a client diagnosed with a paraphilic disorder. Which findings are most likely? (Select all that apply.) a. Childhood history of attention deficit hyperactivity disorder (ADHD) b. A poorly managed endocrine disorder c. History of brain injury d. Cognitive distortions e. Grandiosity
ANS: A, C, D ADHD in childhood, substance abuse, phobic disorders, and major depressive disorder/dysthymia are strongly associated with paraphilic disorders. Errors in thought make it seem acceptable for deviant and destructive sexual behaviors to occur. Clients who have experienced head trauma with damage to the frontal lobe of the brain may display symptoms of promiscuity, poor judgment, inability to recognize triggers that set off sexual desires, and poor impulse control. Endocrine problems are not associated with pedophilic disorder. Self- confidence is lacking; therefore, grandiosity would not be expected.
A patient who is having a tonic-clonic seizure is prescribed Phenobarbital. During administration of this drug, it is important the nurse monitors for: A. Respiratory depression B. Hypertension C. Disseminated intravascular clotting D. Hypotension E. Fever
ANS: A, D This medication stimulates the GABA receptors and helps with inhibitory neurotransmission. It can lead to respiratory depression and hypotension, therefore, it is very important the nurse monitors the patient for this.
The nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Have suction equipment with an airway at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids. d. Have oxygen administration set at the bedside. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.
ANS: A, D, F Oxygen and suctioning equipment with an airway must be readily available. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Padded tongue blades may pose a danger to the client or nurse during a seizure and would not be used. Dietary restrictions and strict bedrest are not interventions associated with epilepsy.
A patient is newly diagnosed with mild ulcerative colitis. What type of anti-inflammatory medication is typically prescribed as first-line treatment for this condition? A. 5-Aminosalicylates (Sulfasalazine) B. Immunomodulators (Adalimumab) C. Corticosteroids (Prednisone) D. Immunosupressors (Azathioprine)
ANS: A. 5-Aminosalicylates (Sulfasalazine) are usually prescribed for mild to moderate cases of ulcerative colitis as first-line treatment. If Aminosalicylates are not working (or the patient is allergic to sulfa) corticosteriods are prescribed. Corticosteriods may be used in combination with immunosupressors. Immunosupressors and immunomodulators are used in severe cases of ulcerative colitis when other medications have not worked.
A patient with ulcerative colitis is scheduled for ileoanal anastomosis (J-Pouch) surgery. You know that this procedure: A. Removes the colon and rectum which allows a pouch to be created that will attach to the ileum. This will allow stool to pass from the small intestine to the anus. B. Removes the colon and rectum and creates a permanent ileostomy. C. Removes the colon and creates a temporary colostomy. D. Removes the rectum which allows a pouch to be created from the colon. This will allow stool to pass from the colon to the anus.
ANS: A. A J-pouch surgery (ileoanal anastomosis) removes the colon and rectum which allows a pouch to be created that will attach to the ileum. This will allow stool to pass from the small intestine to the anus.
You're performing a head-to-toe assessment on a patient with multiple sclerosis. When you ask the patient to move the head and neck downward the patient reports an "electric shock" sensation that travels down the body. You would report your finding to the doctor that the patient is experiencing: A. Romberg's Sign B. Lhermitte's Sign C. Uhthoff's Sign D. Homan's Sign
ANS: B
A patient with a history of epilepsy is taking Phenytoin. The patient's morning labs are back, and the patient's Phenytoin level is 7 mcg/mL. Based on this finding, the nurse will? A. Assess the patient for a rash B. Initiate seizure precautions C. Hold the next dose of Phenytoin D. Continue to monitor the patient
ANS: B A normal Phenytoin level is 10 to 20 mcg/mL. The patient's level is low; therefore, the patient is at risk for seizures. The nurse should initiate seizure precautions. Remember a patient being under medicated is a trigger for developing a seizure.
A patient has been taking an AED for several years as part of his treatment for partial seizures. His wife has called because he ran out of medication this morning and wonders if he can go without it for a week until she has a chance to go to the drugstore. What is the nurse's best response? a. "He is taking another antiepileptic drug, so he can go without the medication for a week." b. "Stopping this medication abruptly may cause withdrawal seizures. A refill is needed right away." c. "He can temporarily increase the dosage of his other anti seizure medications until you get the refill." d. "He can stop all medications because he has been treated for several years now."
ANS: B Abrupt discontinuation of antiepileptic drugs can lead to withdrawal seizures. The other options are incorrect. The nurse cannot change the dose or stop the medication without a prescriber's order.
After teaching a client who is prescribed adalimumab for severe ulcerative colitis (UC), the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "I will avoid large crowds and people who are sick." b. "I will take this medication with my breakfast each morning." c. "Nausea and vomiting are common side effects of this drug." d. "I should wash my hands after I play with my dog."
ANS: B Adalimumab is an immune modulator that is given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good and washing.
The nurse is caring for a client who has a postoperative paralytic ileus following abdominal surgery. What drug is appropriate to manage this nonmechanical bowel obstruction? a. Alosetron b. Alvimopan c. Amitiptyline d. Amlodipine
ANS: B Alvimopan is the appropriate drug to promote peristalsis for clients who have a paralytic ileus. The other drugs do not affect intestinal activity.
A client has a nasogastric (NG) tube as a result of an upper gastrointestinal (GI) hemorrhage. What comfort measure would the nurse remind assistive personnel (AP) to provide? a. Lavaging the tube with ice water b. Performing frequent oral care c. Re-positioning the tube every 4 hours d. Taking and recording vital signs
ANS: B Clients with NG tubes need frequent oral care both for comfort and to prevent infection. Lavaging the tube is done by the nurse. Repositioning the tube, if needed, is also done by the nurse. The can take vital signs, but this is not a comfort measure.
A patient with multiple sclerosis will be starting therapy with an immunosuppressant drug. The nurse expects that which drug will be used? a. Azathioprine (Imuran) b. Glatiramer acetate (Copaxone) c. Daclizumab (Zenapax) d. Sirolimus (Rapamune)
ANS: B Glatiramer acetate and fingolimod are the only immunosuppressants currently indicated for reduction of the frequency of relapses (exacerbations) in a type of multiple sclerosis known as relapsing-remitting multiple sclerosis.
A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication would the nurse anticipate to prepare for administration? a. Atenolol b. Lorazepam c. Phenytoin d. Lisinopril
ANS: B Initially, intravenous lorazepam or diazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These drugs are typically administered for hypertension and heart failure.
The nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate for migraine headaches. Which condition would alert the nurse to withhold the medication and contact the primary health care provider? a. Bronchial asthma b. Heart disease c. Diabetes mellitus d. Rheumatoid arthritis
ANS: B Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine headache by binding to serotonin receptors and triggering cranial vasoconstriction. Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in clients with heart disease, hypertension, or Prinzmetal angina. The other conditions would not affect the client's treatment.
The nurse is assessing for fatigue in a patient diagnosed with multiple sclerosis. Which self-reporting tool is best for the nurse to utilize? a. Multidimensional Assessment of Fatigue (MAF) b. Fatigue Severity Scale (FSS) c. Brief Fatigue Inventory (BNFI) d. Multidimensional Fatigue Inventory (MFI)
ANS: B The FSS was developed for patients with multiple sclerosis and lupus. The MAF was designed for arthritis patients and is also used in cancer patients and those with chronic pulmonary disease. The BFI is used for cancer patients. The MFI is used with various patient populations, including cancer, chronic fatigue syndrome, and COPD.
You're educating a 25-year-old female about possible triggers for seizures. Which statement requires you to re-educate the patient about the triggers? A. "I'm at risk for seizure activity during my menstrual cycle." B. "I will limit my alcohol intake to 2 glasses of wine per day." C. "It's important I get plenty of sleep." D. "I will be sure to stay hydrated, especially during hot weather."
ANS: B The patient should avoid all alcohol because it can lead to a seizure. Hormone shifts (menstrual cycle, ovulation, pregnancy) sleep deprivation, and dehydration can lead to a seizure.
You're developing discharge instructions to the parents of a child who experiences atonic seizures. What information below is important to include in the teaching? A. "This type of seizure is hard to detect because the child may appear like he or she is daydreaming." B. "Be sure your child wears a helmet daily." C. "It is common for the child to feel extremely tired after experiencing this type of seizure." D. "Avoid high fat and low carbohydrate diets."
ANS: B This type of seizure leads to a sudden loss of muscle tone. The patient will go limp and fall, which when this happens the head is usually the first part of the body to hit the floor or an object nearby. It is important the child wears a helmet daily to protect their head from injury. Option A is a characteristic of an absence seizure. Option C is a characteristic of a tonic-clonic seizure during the post ictus stage. And option D is wrong because some patients benefit from this type of diet known as the ketogenic diet.
A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod. For which common side effect would the nurse monitor? a. Peripheral edema b. Facial flushing c. Tachycardia d. Fever
ANS: B Fingolimod is an oral immunomodulator that has two common side effects—facial flushing and GI disturbance, such as diarrhea. Peripheral edema, tachycardia, and fever are not common side effects of this drug.
You're developing a plan of care for a patient with multiple sclerosis who presents with Uhthoff's Sign. What interventions will you include in the patient's plan of care? Select all that apply: A. Avoid movements of the head and neck downward B. Keep room temperature cool C. Encourage patient to use warm packs and heating pads for symptoms D. Educate the patient on three ways to avoid overheating during exercise
ANS: B, D. Uhthoff's Sign is where when the patient experiences too much heat their symptoms increase and get worst. Therefore, it is important the patient stays cool and doesn't overheat (overheating can come from outside temperatures, exercise, emotional events etc.). The room should be cool and the patient should be encouraged to exercise but to avoid overheating.
Your patient is scheduled for a lumbar puncture to help diagnose multiple sclerosis. The patient wants clarification about what will be found in the cerebrospinal fluid during the lumbar puncture to confirm the diagnosis of MS. You explain that ____________ will be present in the fluid if MS is present. A. high amounts of IgM B. oligoclonal bands C. low amounts of WBC D. oblong red blood cells and glucose
ANS: B. These specific proteins, oligoclonal bands, which are immunoglobulins will be found in the CSF. This demonstrates there is inflammation in the CNS and is a common finding in multiple sclerosis.
You're providing education to a patient with severe ulcerative colitis about Adalimumab. Which statement by the patient is CORRECT? A. "This medication is used as first-line treatment for ulcerative colitis." B. "My physician will order a TB skin test before I start taking this medication." C. "This medication works by increasing the tumor necrosis factor protein which helps decrease inflammation." D. "This medication is a corticosteroid. Therefore, I need to monitor my blood glucose levels regularly."
ANS: B. Before starting Adalimumab, the physican may order the patient to be checked for TB. Adalimumab is a immunomodulator (NOT corticosteriod) that suppresses the immune system by BLOCKING (not increasing) the tumor necrosis factor protein which helps decrease inflammation. Therefore, the patient is at risk for developing infections such as TB (tuberculosis). In addition, if the patient has or had TB, this medication could exacerbate the disease. This medication is used for only severe cases (NOT first-line treatment).
A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment would the nurse complete first? a. Inspection of oral mucosa b. Recent dietary intake c. Heart rate and rhythm d. Percussion of abdomen
ANS: C Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client would have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this patient than heart rate and rhythm.
Your patient has entered the post ictus stage for seizures. The patient's seizure presented with an aura followed by body stiffening and then recurrent jerking. The patient had incontinence and bleeding in the mouth from injury to the tongue. What is an expected finding in this stage based on the type of seizure this patient experienced? A. Crying and anxiety B. Immediate return to baseline behavior C. Sleepy, headache, and soreness D. Unconsciousness
ANS: C Based on the findings during the seizure the patient experienced a tonic-clonic seizure. In the post ictus stage (after the seizure) the patient is expected to be sleepy (very tired), have soreness, and a headache. The nurse should let the patient sleep.
A client with multiple sclerosis is being discharged from rehabilitation. Which statement would the nurse include in the client's discharge teaching? a. "Be sure that you use a wheelchair when you go out in public." b. "Wear an undergarment brief at all times in case of incontinence." c. "Avoid overexertion, stress, and extreme temperature if possible." d. "Avoid having sexual intercourse to conserve energy."
ANS: C Clients who have multiple sclerosis have chronic fatigue and are prone to disease exacerbation (flare-up) is they overexert, are stressed, or are exposed to extreme temperature and humidity. They should not wear briefs unless they have actual problems with continence and should not use a wheelchair if they are able to ambulate with a cane or walker. Maintaining independence and self-esteem is important, so participating in sexual activities is encouraged.
The nurse assesses a client who has a history of migraines. Which symptom would the nurse identify as an early sign of a migraine with aura? a. Vertigo b. Lethargy c. Visual disturbances d. Numbness of the tongue
ANS: C Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other symptoms are not associated with an impending migraine with aura.
Neurons in the brain are tasked with handling and transmitting information. There are different types of neurons, such as excitatory and inhibitory. Excitatory neurons release the neurotransmitter _____________, while inhibitory neurons release the neurotransmitter ________________. A. GABA, glutamate B. Norepinephrine, GABA C. Glutamate, GABA D. Dopamine, glutamate
ANS: C Excitatory neurons release glutamate and inhibitory neurons release GABA.
A nurse asks a client to take deep breaths during an electroencephalography. The client asks, "Why are you asking me to do this?" How would the nurse respond? a. "Hyperventilation causes vascular dilation of cerebral arteries, which decreases electoral activity in the brain." b. "Deep breathing helps you to relax and allows the electroencephalograph to obtain a better waveform." c. "Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity." d. "Deep breathing will help you to blow off carbon dioxide and decreases intracranial pressures."
ANS: C Hyperventilation produces cerebral vasoconstriction and alkalosis, which increase the likelihood of seizure activity. The client is asked to breathe deeply 20 times for 3 minutes. The other responses are not accurate.
A patient has a 9-year history of a seizure disorder that has been managed well with oral phenytoin (Dilantin) therapy. He is to be NPO (consume nothing by mouth) for surgery in the morning. What will the nurse do about his morning dose of phenytoin? a. Give the same dose intravenously. b. Give the morning dose with a small sip of water. c. Contact the prescriber for another dosage form of the medication. d. Notify the operating room that the medication has been withheld.
ANS: C If there are any questions about the medication order or the medication prescribed, contact the prescriber immediately for clarification and for an order of the appropriate dose form of the medication. Do not change the route without the prescriber's order. There is an increased risk of seizure activity if one or more doses of the AED are missed.
The nurse is caring for a client who has been diagnosed with peptic ulcer disease. For which complication would the nurse monitor? a. Large bowel obstruction b. Dyspepsia c. Upper gastrointestinal (GI) bleeding d. Gastric cancer
ANS: C Peptic ulcer disease (PUD) can cause gastric mucosal damage or perforation, which causes upper GI bleeding. Dyspepsia is a symptom of PUD, gastritis, and gastric cancer. PUD affects the stomach and/or duodenum, not the colon.
A desired outcome for a 12-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) is to improve relationships with other children. Which treatment modality should the nurse suggest for the plan of care? a. Reality therapy b. Simple restitution c. Social skills group d. Insight-oriented group therapy
ANS: C Social skills training teaches the child to recognize the impact of his or her behavior on others. It uses instruction, role playing, and positive reinforcement to enhance social outcomes. The other therapies would have lesser or no impact on peer relationships.
The nurse is caring for a patient who is experiencing alcohol withdrawal. What is the highest priority for this patient? a. Describe how the alcohol is causing the withdrawal effects. b. Leave the patient by him/herself so as not to cause agitation. c. Promote a safe, calm, and comfortable environment. d. Refer the patient to an alcohol-abuse counselor.
ANS: C The main priority is the patient's safety due to risk of harm from seizures, DTs, and anxiety. The nurse could provide referrals or discuss the relationship of alcohol to physical problems after the withdrawal period is over. Do not leave the patient alone, as many patients will need reassurance that they will survive the ordeal of withdrawal.
What is the nurse's priority focused assessment for side effects in a child taking methylphenidate for attention deficit hyperactivity disorder (ADHD)? a. Dystonia, akinesia, and extrapyramidal symptoms b. Bradycardia and hypotensive episodes c. Sleep disturbances and weight loss d. Neuroleptic malignant syndrome
ANS: C The most common side effects are gastrointestinal disturbances, reduced appetite, weight loss, urinary retention, dizziness, fatigue, and insomnia. Weight loss has the potential to interfere with the child's growth and development. The distracters relate to side effects of conventional antipsychotic medications.
The patient is experiencing a tonic-clonic seizure. The seizure started at 1402 and it is now 1408, and the patient is still experiencing a seizure. The nurse should? A. Continue to monitor the patient B. Suction the patient C. Initiate the emergency response system D. Restrain the patient to prevent further injury
ANS: C Tonic-clonic seizures should last about 1-3 minutes. If the seizure lasts MORE than 5 minutes, the patient needs medical treatment FAST to stop the seizure....this is known as status epilepticus.
When teaching a patient about taking a newly prescribed antiepileptic drug (AED) at home, the nurse will include which instruction? a. "Driving is allowed after 2 weeks of therapy." b. "If seizures recur, take a double dose of the medication." c. "Antacids can be taken with the AED to reduce gastrointestinal adverse effects." d. "Regular, consistent dosing is important for successful treatment."
ANS: D Consistent dosing, taken regularly at the same time of day, at the recommended dose, and with meals to reduce the common gastrointestinal adverse effects, is the key to successful management of seizures when taking AEDs. Noncompliance is the factor most likely to lead to treatment failure.
After teaching a client who is diagnosed with new-onset epilepsy and prescribed phenytoin, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. "To prevent complications, I will drink at least 2 L of water daily." b. "This medication will stop me from getting an aura before a seizure." c. "I will not drive a motor vehicle while taking this medication." d. "Even when my seizures stop, I will continue to take this drug."
ANS: D Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The drug will not stop an aura before a seizure.
The nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How would the nurse document this type of seizure? a. Atonic b. Myoclonic c. Absence d. Tonic-clonic
ANS: D Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur singly or in groups. Absence seizures present with automatisms, and the client is unaware of his or her environment.
When a 5-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) bounces out of a chair and runs over and slaps another child, what is the nurse's best action? a. Instruct the parents to take the aggressive child home. b. Direct the aggressive child to stop immediately. c. Call for emergency assistance from other staff. d. Take the aggressive child to another room.
ANS: D The nurse should manage the milieu with structure and limit setting. Removing the aggressive child to another room is an appropriate consequence for the aggressiveness. Directing the child to stop will not be effective. This is not an emergency. Intervention is needed rather than sending the child home.
During a routine appointment, a patient with a history of seizures is found to have a phenytoin (Dilantin) level of 23 mcg/mL. What concern will the nurse have, if any? a. The patient is at risk for seizures because the drug level is not at a therapeutic level. b. The patient's seizures should be under control because this is a therapeutic drug level. c. The patient's seizures should be under control if she is also taking a second antiepileptic drug. d. The drug level is at a toxic level, and the dosage needs to be reduced.
ANS: D Therapeutic drug levels for phenytoin are usually 10 to 20 mcg/mL. The other options are incorrect.
A 7-year-old male patient is being evaluated for seizures. While in the child's room talking with the child's parents, you notice that the child appears to be daydreaming. You time this event to be 10 seconds. After 10 seconds, the child appropriately responds and doesn't recall the event. This is known as what type of seizure? A. Focal Impaired Awareness (complex partial) B. Atonic C. Tonic-clonic D. Absence
ANS: D This is an absence seizure and is most common in children. The hallmark of it is staring that appears to be like a daydreaming state. It is very short and the post ictus stage of this type of seizure is immediate.
