Seizures

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. 32-year-old with a blood glucose of 20 mg/dLB. 63-year-old whose CT scan shows an ischemic strokeC. 72-year-old who is post op day 5 from open heart surgeryD. 16-year-old with bacterial meningitisE. 58-year-old experiencing ETOH withdrawal

A. 32-year-old with a blood glucose of 20 mg/dLB. 63-year-old whose CT scan shows an ischemic strokeD.16-year-old with bacterial meningitisE.58-year-old experiencing ETOH withdrawal

Which is the earliest sign of increasing intracranial pressure? Vomiting Change in level of consciousness Headache Posturing

Change in level of consciousness The earliest sign of increasing intracranial pressure (ICP) is a change in level of consciousness. Other manifestations of increasing ICP are vomiting, headache, and posturing.

During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect? Alopecia Gingival hyperplasia Diplopia Ataxia

Gingival hyperplasia

Which of the following drugs may be used after a seizure to maintain a seizure-free state? Valium Phenobarbital Ativan Cerebyx

Phenobarbital IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin (Cerebyx) are administered slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are administered later to maintain a seizure-free state. In general, a single drug is used to control the seizures.

A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? 3 6 9 15

3 Each criterion in the Glasgow Coma Scale (eye opening, verbal response, and motor response) is rated on a scale from 3 to 15. A total score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive.

The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child? An absence seizure A myoclonic seizure A partial seizure A tonic-clonic seizure

An absence seizure Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. Both myoclonic and tonic-clonic seizures involve jerking movements.

Which characteristic of a patient's recent seizure is consistent with a focal seizure?A. The patient lost consciousness during the seizure. B. The seizure involved lip smacking and repetitive movements.C. The patient fell to the ground and became stiff for 20 seconds.D. The etiology of the seizure involved both sides of the patient's brain.

B. The seizure involved lip smacking and repetitive movements.The most common complex focal seizure involves lip smacking and automatisms (repetitive movements that may not be appropriate). Loss of consciousness, bilateral brain involvement, and a tonic phase are associated with generalized seizure activity.

To meet the sensory needs of a client with viral meningitis, the nurse should: minimize exposure to bright lights and noise. promote an active range of motion. increase environmental stimuli. avoid physical contact between the client and family members.

minimize exposure to bright lights and noise. Photophobia and hypersensitivity to environmental stimuli are the common clinical manifestations of meningeal irritation and infection. Therefore, the nurse should provide a calm environment with less stressful stimuli. Physical activity may worsen symptoms; therefore, physical activity should be reduced. Family members do not need to be avoided. People diagnosed with viral meningitis should be instructed to thoroughly wash hands frequently.

A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements? "In most people, epilepsy is usually synonymous with intellectual disability." "For many people with epilepsy, the disorder is synonymous with mental illness." "Many people with developmental disabilities resulting from neurologic damage also have epilepsy." "Cases of epilepsy are often associated with intellectual level."

"Many people with developmental disabilities resulting from neurologic damage also have epilepsy." Many people who have developmental disabilities because of serious neurologic damage also have epilepsy. Epilepsy is not associated with intellectual level. It is not synonymous with intellectual disability or mental illness.

The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions? 1. "I will use a straw for drinking." 2. "I will drive only during the daytime." 3. "I will be careful because the device alters balance." 4. I will wash the skin daily under the lamb's wool liner of the vest."

2. "I will drive only during the daytime." : The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be chan- ged if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all because the device impairs the range of vision.

The patient with type 1 diabetes mellitus with hypoglycemia is having a seizure. Which medication should the nurse anticipate administering to stop the seizure?A. IV dextrose solutionB. IV diazepam (Valium)C. IV phenytoin (Dilantin)D. Oral carbamazepine (Tegretol)

A. IV dextrose solutionThis patient's seizure is caused by low blood glucose, so IV dextrose solution should be given first to stop the seizure. IV diazepam, IV phenytoin, and oral carbamazepine would be used to treat seizures from other causes such as head trauma, drugs, and infections.

The nurse provides information to the caregiver of a 68-year-old man with epilepsy who has tonic-clonic seizures. Which statement, if made by the caregiver, requires further teaching?A. "It is normal for a person to be sleepy after a seizure."B. "I should call 911 if breathing stops during the seizure."C. "The jerking movements may last for 30 to 40 seconds."D. "Objects should not be placed in the mouth during a seizure."

B. "I should call 911 if breathing stops during the seizure."Caregivers do not need to call an ambulance or send a person to the hospital after a single seizure unless the seizure is prolonged, another seizure immediately follows, or extensive injury has occurred. Altered breathing is a clinical manifestation of a tonic-clonic seizure. Contact emergency medical services (or call 911) if breathing stops for more than 30 seconds. No objects (e.g., oral airway, padded tongue blade) should be placed in the mouth. Lethargy is common in the postictal phase of a seizure. Jerking of the extremities occurs during the clonic phase of a tonic-clonic seizure. The clonic phase may last 30 to 40 seconds.

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? The type of anticonvulsant prescribed to manage the epileptic condition Recent stress level Recent weight gain and loss Compliance with the prescribed medication regimen

Compliance with the prescribed medication regimen The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.

Aclient with Parkinson's disease develops akinesia while ambu- lating, increasing the risk for falls. Which suggestion should the nurse provide to the client to alleviate this problem? Use a wheelchair to move around. Stand erect and use a cane to ambulate. Keep the feet close together while ambulating and use a walker. Consciously think about walking over imaginary lines on the floor

Consciously think about walking over imaginary lines on the floor Step with wide steps, marching, or going over imaginary lines will help with freeze ups Clients with Parkinson's dis- ease can develop bradykinesia (slow movement) or akinesia (freezing or no movement). Having these clients imagine lines on the floor to walk over can keep them moving forward while remaining safe.

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication? Lamictal Lamisil Labetalol Lomotil

Lamictal Lamictal is an antiseizure medication. Its packaging was recently changed in an attempt to reduce medication errors, because this medication has been confused with Lamisil (an antifungal), labetalol (an antihypertensive), and Lomotil (an antidiarrheal).

A client with meningitis has a history of seizures. Which should the nurse do to safely manage the client during a seizure? Select all that apply. Turn the client to the side. Physically restrain the client's movements. Inspect the oral cavity and teeth. Provide verbal reassurance.

Turn the client to the side. Provide verbal reassurance. Turning client to the side will allow accumulated saliva to drain from the mouth. The person may not be able to hear you while unconscious, but verbal assurances will help as the person is regaining consciousness. Physically restraining a client during a seizure increases the potential for injuries. Inspection of oral cavity occurs after a generalized seizure and not during a seizure.

A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, Cogentin, and Eldepryl. The nurse knows that most likely, the client has a diagnosis of ________. a) Seizure disorder b) Huntington's disease c) Parkinson's disease d) Multiple sclerosis

c) Parkinson's disease Parkinson's diseaseThese drugs are commonly used in the medical management of Parkinson's disease.

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: hold the client's arm still to keep him from hitting anything. carefully move the client to a flat surface and turn him on his side. allow the client to remain in the chair but move all objects out of his way. place an oral airway in the client's mouth to maintain an open airway.

carefully move the client to a flat surface and turn him on his side. When caring for a client experiencing a tonic-clonic seizure, the nurse should help the client to a flat non-elevated surface and then position him on his side to ensure that he doesn't aspirate and to protect him from injury. These steps help reduce the risk of injury from falling or hitting surrounding objects and help establish an open airway. The client shouldn't be restrained during the seizure. Also, nothing should be placed in his mouth; anything in the mouth could impair ventilation and damage the inside of the mouth.

The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Which is the nurse's priority concern? Airway clearance Risk of injury Deficient fluid volume Risk for impaired skin integrity

Airway clearance The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.

Which is a late sign of increased intracranial pressure (ICP)? Irritability Slow speech Altered respiratory patterns Headache

Altered respiratory patterns Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache, irritability, and any change in LOC are early signs of increased ICP. Speech changes, such as slowed speech or slurring, are also early signs of increased ICP.

After a seizure, the nurse should place the patient in which of the following positions to prevent complications? High Fowler's, to prevent aspiration Side-lying, to facilitate drainage of oral secretions Supine, to rest the muscles of the extremities Semi-Fowler's, to promote breathing

Side-lying, to facilitate drainage of oral secretions To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration.

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? Seizure began at 1300 hours. The client cried out before the seizure began. Seizure was 1 minute in duration including tonic-clonic activity. Sleeping quietly after the seizure

Seizure was 1 minute in duration including tonic-clonic activity. Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and their skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.