Jackson Weber Complex Pre/Post Quiz
When the nurse assists Jackson with ambulation to the bathroom, he starts to have a seizure. Which of the following actions should the nurse take first?
Assist Jackson in slowly descending to the floor Rationale: If a patient is standing or sitting when seizure activity occurs, easing the patient to the ground can help prevent further injury, especially head injuries. All other actions should be conducted after assisting the patient to the floor.
The nurse is preparing to administer intravenous (IV) lorazepam to a patient who is experiencing status epilepticus. The nurse attempts to flush the patient's peripheral IV line and determines that the line is not patent. The patient has weight-appropriate doses ordered of IV lorazepam, oral phenobarbital, and diazepam rectal gel (Diastat). Which of the following is the most appropriate action for the nurse to take at this time?
Administer diazepam per rectum Rationale:The most appropriate and safest route to administer the anticonvulsant at this time is per rectum, and the patient has an order for diazepam rectal gel. Diazepam rectal gel is specifically formulated and prepared as a gel to be administered rectally in the event of cluster seizures or status epilepticus. The nurse should avoid attempting IV catheter insertion during an active seizure because injuries can occur. The patient cannot take oral medications during continuous seizure activity. Intraosseous access is not indicated at this time
Jackson's first dose of phenobarbital following the loading dose is due and he is in the hospital playroom. Which of the following actions should the nurse take at this time?
Have Jackson come back to his room to take the medication before returning to the playroom. Rationale:All medications should be administered in the patient's room to reduce the risk of medical errors and to ensure that all the steps of the medication administration process are followed. The hospital playroom is considered a "safe" space, and nursing interventions should not be performed in the playroom, even if considered nonthreatening by the nurse. The nurse should not delay administration of the prescribed medication but should give it when it is due.
Jackson was given a dose of lorazepam to stop status epilepticus. Following cessation of the seizure, Jackson's mother asks why he is so sleepy. What is the best response by the nurse?
He is experiencing the postictal phase, which means that he is very drowsy following a seizure. Jackson will need to be monitored closely during this phase until he wakes up fully. Rationale: During the postictal phase, patients will be semicomatose or in a deep sleep for approximately 30 minutes to 2 hours and may only respond to painful stimuli. Close monitoring is imperative with management of basic life support (airway, breathing, and circulation) as needed.
The nurse is preparing discharge teaching for Jackson and his mother regarding seizure prevention. Jackson's mother states that she does not understand why he needs to take the phenobarbital daily now that his seizures are under control. Which of the following nursing diagnoses is the priority to include in the plan of care?
Ineffective Health Maintenance related to lack of knowledge regarding anticonvulsive therapy Rationale:The importance of administering anticonvulsant medications daily at the same time, along with compliance with regular follow-up visits and drug levels, needs to be emphasized in teaching geared toward Jackson's mother at a level and in a modality that she can best process and understand.
While the nurse is in the room with Jackson, he begins experiencing status epilepticus. Which of the following medication orders is the priority for the nurse to administer at this time?
Lorazepam 2 mg intravenous (IV) push Rationale: Lorazepam, an anticonvulsant, should be given first to suppress the spread of seizure activity. Phenobarbital loading dose and maintenance IV fluids should be started after the cessation of seizure activity. Oral phenobarbital can be administered on the scheduled timeframe as ordered by the provider once the patient regains consciousness.
A nurse has an order to administer D5 NS + 20 mEq KCl/L at a maintenance rate for a child who recently experienced a seizure. What is the hourly maintenance fluid requirement in milliliters for a patient weighing 40 lb? Round your answer to the nearest whole number. ________
59 Rationale:Daily maintenance fluid requirement is calculated using the 100-50-20 formula. Convert pounds to kilograms: 40 ÷ 2.2 = 18.2 kg. Multiply 100 by the first 10 kg: 100 × 10 = 1,000. Multiply 50 by the second 10 kg: 50 × 8.2 = 410. Add the sum of the calculations together to get the daily fluid maintenance: 1,000 + 410 = 1,410. Divide daily fluid maintenance by 24 to get the hourly fluid maintenance rate: 1,410 ÷ 24 = 58.75 mL/hr. Round 58.75 mL/hr to 59 mL/hr.
A nurse is documenting in the patient's medical record after witnessing the patient's seizure activity. Which of the following examples of seizure documentation includes all elements necessary for documenting seizure activity?
At 0800, the patient reported dizziness and then experienced a seizure with tonic-clonic movements of entire body lasting 1 minute. Patient unconscious during seizure activity. Following seizure, patient sleepy with shallow respirations of 16 breaths per minute and oxygen saturations of 98%. Rationale:Documentation of witnessed seizure activity should include time of seizure onset, description and characteristics of seizure activity, and length of seizure activity. A description of the patient's behavior during and after the event, including any precipitating factors, should also be included.
The nurse has communicated with the provider using the situation-background-assessment-recommendation (SBAR) method regarding a patient experiencing prolonged seizures. Following this initial communication, what steps does the nurse need to take to complete the process? (Select all that apply.)
Document the communication with the provider, the interventions taken, and the patient's response, Develop a follow-up plan in collaboration with the provider receiving the communication, Review the decisions made to resolve the problem and provide opportunity for clarification Rationale:Following the communication with the provider using the SBAR method, the nurse should complete the process by providing an opportunity for information to be clarified and for questions to be asked. Both individuals involved in the conversation should review the decisions made to resolve the problem. A follow-up plan should be developed in collaboration with the provider receiving the communication, and the communication should be documented along with any interventions taken and the patient's response to the interventions. The nurse should introduce himself or herself during the situation component of the communication with the provider, not following the conversation. Pertinent information and history related to the current problem should be communicated to the provider during the background component of the conversation, not following the conversation.
A nurse is caring for a 5-year-old patient who became very upset during blood specimen collection. The patient demanded that an adhesive bandage be placed immediately after the specimen was obtained to cover the hole in the skin caused by the blood collection needle. This need is developmentally related to which of the following stressors of hospitalization?
Fear of mutilation Rationale:Although preschoolers may experience other stressors related to hospitalization, the primary stressor is fear of mutilation and invasive procedures, as they do not understand the body's integrity.
When teaching Jackson about managing his epilepsy at home, which developmentally appropriate interventions would the nurse include to promote self-care? (Select all that apply.)
Give him the choice of taking the medication from a syringe or a medication cup. Have him help his mother gather the supplies needed for medication administration when the medication is due. Rationale:It is important to allow the patient some control and involvement in decision-making and daily care activities. Offer simple choices whenever possible, as in choosing whether the patient wants to take the medicine from a cup or syringe, but don't offer choices when there are no alternatives, such as whether the medication is taken with a meal or hours later. Developmentally, a 5-year-old would not be able to keep detailed records regarding seizure activity. Although his role may be limited, Jackson is not too young to be involved in his care. At his age, Jackson could help his mother gather supplies when it is time to take his medication.
The mother of a preschool-aged patient asks what can be done to help reduce the risk of injury during seizures following discharge. Which of the following should the nurse's response include? (Select all that apply.)
Have the patient wear a medical alert identification necklace at all times., Confirm that all preschool workers know how to recognize and manage seizures., Monitor the patient when bathing to reduce the risk of submersion during a seizure., Keep a bag containing rescue medicine at home, preschool, and wherever the patient goes. Rationale:Patients with epilepsy should be treated the same as those without a neurological disorder to aid in the development of a positive self-image and increased self-esteem. It is important for parents and health care providers to teach school nurses, staff, and teachers about the patient's seizure disorder and how to recognize and manage acute seizure activity. Persons with seizure disorders should wear a medical identification alert bracelet or necklace and carry prescribed rescue medications with them at all times. Educate parents and children on any restrictions and encourage parents to place only necessary restrictions on the child, such as monitoring when bathing.
The nurse is teaching a 5-year-old patient how to prevent injury if a seizure occurs while the patient is playing. Which of the following statements indicates that teaching has been effective?
I should tell someone to get help if I feel dizzy or weird when I'm playing. Rationale:Patients with epilepsy should be treated the same as those without a neurological disorder to aid in the development of a positive self-image and increased self-esteem. Preschoolers are not mature enough to be left unsupervised while swimming even if they have had swimming lessons. In addition, supervision is recommended during swimming or other potentially hazardous activities to reduce the risk of injury in the event of seizure activity. Preschoolers are not mature enough to ride a bicycle in the street and should ride on the sidewalk; helmets and pads should be worn at all times when riding a bicycle. Any activity limitations will be based on the type, frequency, and severity of the seizures the patient has.
A nurse is called to the bedside to evaluate a 5-year-old patient who experienced a prolonged tonic-clonic seizure that stopped after administration of intravenous (IV) lorazepam. The patient responds only to painful stimuli and has shallow, snoring respirations at a rate of 6 breaths per minute. Which of the following is the most appropriate action for the nurse to take next?
Open the airway and support respiratory efforts with bag-valve-mask ventilation if needed Rationale: The patient's presentation is consistent with the postictal phase following a tonic-clonic seizure, which can range from 30 minutes to 2 hours in duration. Notifying the provider would be appropriate in this situation. Manual ventilation is indicated to help the patient maintain a patent airway. The patient should be monitored closely until the level of consciousness returns to baseline in case the patient deteriorates and further intervention is needed, such as intubation. Oxygen via a nonrebreather mask or nasal cannula would not help the patient maintain a patent airway.
A nurse is explaining to a caregiver the difference between status epilepticus and other types of seizures or seizure conditions. Which of the following best describes status epilepticus?
Prolonged or clustered seizures in which consciousness does not return between seizures Rationale:Status epilepticus is a neurologic, life-threatening emergency characterized by prolonged or clustered seizures in which consciousness does not return between seizures. Administration of anticonvulsants to cease seizure activity is key, along with management of basic life support: airway, breathing, and circulation. Sudden cessation of activity combined with a blank facial expression lasting less than 30 seconds is characteristic of an absence seizure. Any seizure activity related to a drastic increase in core body temperature secondary to viral illness or underlying bacterial infection is characteristic of a febrile seizure. Febrile seizures can be associated with status epilepticus, but not all instances of status epilepticus are febrile. Tonic-clonic contractions of the entire body, followed by a postictal phase lasting between 30 minutes and 2 hours are characteristic of tonic-clonic seizures.
What techniques can the nurse employ when planning education for Jackson and his mother to aid in the understanding of seizure management and prevention? (Select all that apply.)
Provide written teaching handouts with simple explanations and pictures., Involve Jackson and his mom in daily care and give him simple choices as appropriate., Allow Jackson and his mom time to adjust to the hospital and repeat information as needed., Gear teaching toward Jackson's developmental level and his mother's reading level. Rationale:It is important to provide patients and families with written handouts and visuals at a level and in a language that they can understand to help reinforce communication and teaching. Allowing time for the patient and family to adjust to the stressors of hospitalization or diagnosis will help facilitate adjustment and the ability to learn and participate in care. Including the patient and family in daily care allows them to have a sense of control during hospitalization and may help them develop a routine that can be continued at home after discharge. All communication and teaching including discharge education should be provided in small increments throughout hospitalization and reinforced as necessary to avoid information overload. Repetition of information allows for the patient and family to have time to learn and understand.
The nurse is assessing a preschool-aged patient who arrived at the emergency room with generalized tonic-clonic seizures. Which component of the neurological assessment has the highest priority?
Scoring the Pediatric Glasgow Coma Scale Rationale:The physical examination should begin with observation of the patient's level of consciousness, noting a decrease or significant changes. The Pediatric Glasgow Coma Scale is a scale used to standardize the degree of consciousness. It consists of three parts: eye opening, verbal response, and motor response. Testing reflexes, cranial nerve function, and sensory function are all components of a comprehensive neurological assessment, but they are not the highest priority.
The nurse has obtained a detailed health history from a pediatric patient's mother, during which the patient's mother reveals that she is unemployed and cannot afford the patient's prescribed anticonvulsant medication for seizure management. To encourage compliance with the medication regimen, the nurse should request that the provider order a consultation with which of the following departments to assist with financial resources?
Social services Rationale:Many children and families are uninsured or underinsured and may have difficulty paying for medical care. It is imperative that nurses assess for financial barriers to health care and be aware of resources available to help families overcome these barriers. Social services can assist with case management and help families find much-needed resources related to medical care in the hospital setting and in the community. Visits from pastoral care or spiritual leaders can be incorporated into the patient's plan of care when working to recognize and respect the beliefs of the patient and family and to provide support in the hospital setting; however, this would not be a primary source for financial resources in the community. Child life specialists work in conjunction with the parents and health care providers to foster an atmosphere that reduces the overall stress of hospitalization and promotes the child's well-being. Occupational therapists provide therapy directly related to the patient's ability to perform self-care and participate in activities of daily living.
While reviewing Jackson's lab results, the nurse notes that his serum phenobarbital level is below the level to be considered therapeutic. When the nurse questions Jackson's mother about daily medication administration, she tells the nurse that she has lost her job and is unable to afford the cost of Jackson's seizure medications as a single parent. Which of the following is the best response by the nurse?
There may be other resources available to help with the cost of the medication. I will get the social worker to come up and meet with you. Rationale:Many patients and families are unable to pay for costs related to medical services, do not have insurance, or have insurance coverage that is not sufficient to cover medical needs. It is important for nurses to assess for financial barriers related to health care and compliance with treatment and to be aware of resources to help overcome these barriers. Simply telling the mother that she must find a way to pay for the medication and threatening to call Child Protective Services would not be helpful and supportive of the mother. The nurse does not have the authority to change the child's medication order.
The nurse is called to the bedside of a 5-year-old patient experiencing a tonic-clonic seizure. Upon arrival, seizure activity has ceased. The patient is sleepy with a respiratory rate of 14 and oxygen saturations of 98% with no signs of respiratory distress. Which of the following nursing actions would be most appropriate at this time?
Turn patient on side and monitor closely until level of consciousness returns to normal Rationale:The patient's presentation is consistent with the postictal phase following a tonic-clonic seizure, which can range from 30 minutes to 2 hours in duration. The patient has a patent airway with no signs of respiratory distress. Application of oxygen and manual ventilation are not indicated at this time; however, the patient should be monitored closely for return to baseline level of consciousness or any signs of impending deterioration. The patient should be placed in a side-lying position to help maintain a patent airway and decrease the risk for aspiration. If the patient is unable to maintain the airway, the nurse should perform jaw thrust maneuvers to assist in maintaining patency. Clearance of secretions by the nurse will help reduce the risk for aspiration in the patient and ensure that manual ventilation is effective.
