28Qw/exp (contains some pharm Q from quiz) Seizures & Stroke
Which intervention is MOST effective in minimizing the risk of seizure activity in a client who is undergoing diagnostic studies after having experienced several episodes of seizures? (1) maintain the client on bed rest (2) administer butabarbital sodium 30 mg PO, 3x per day (3) close the door to the room to minimize stimulation (4) administer carbamazepine 200mg PO, 2x per day
Answer: 4 Carbamazepine is an anticonvulsant that helps prevent further seizures and is the most effective intervention for prevention seizure risk while the client is undergoing diagnostic tests for seizures. Bed rest, sedation (phenobarbital), and providing privacy do not minimize risk of seizures
Which statement by a client with a seizure disorder who has been prescribed topiramate indicates the client has understood the nurse's instruction about this drug? (1) I will take this medicine before going to bed (2) I will drink 6 - 8 glasses of water a day (3) I will eat plenty of fresh fruits (4) I will take the medicine w a meal or snack
Answer: 2 Toxic effects of topiramate include nephrolithiasis, and clients are encouraged to drink 6 - 8 glasses of water a day to dilute the urine and flush the renal tubules to avoid stone formation. Topiramate is taken in divided doses because it produces drowsiness. Although eating fresh fruits is desirable from a nutritional standpoint, this is not related to topiramate. The drug does not have to be taken with meals.
The nurse is teaching a client to recognize an aura. The nurse should instruct the client to note: (1) a postictal state of amnesia (2) a hallucination that occurs during a seizure (3) a symptom that occurs just before a seizure (4) a feeling of relaxation as the seizure begins to subside
Answer: 3 An aura is a premonition of an impending seizure. Auras usually are of a sensory nature (e.g. an olfactory, visual, gustatory, or auditory sensation); some may be psychic nature. Evaluating an aura may help identify the area of the brain from which the seizure originates. Auras occur before a seizure, not during or after (postictal). They are not similar to hallucinations or amnesia or related to relaxation.
The client will have an EEG in the morning. The nurse should instruct the client to have which foods/fluids for breakfast? (1) no food or fluids (2) only coffee or tea if needed (3) a full breakfast as desired without coffee, tea, or energy drinks (4) a liquid breakfast of fruit juice, oatmeal, or smoothie
Answer: 3 Beverages contain caffeine, such as coffee, tea, cola, and energy drinks, are withheld before an EEG because of the stimulating effects of the caffeine on the brain waves. A meal should not be omitted before an EEG because low blood sugar could alter brain wave patterns; the client can have the entire meal except for the coffee. The client does not need to be on a liquid diet or NPO
The client is scheduled to receive phenytoin through an NG tube and has a tube-feeding supplement running continuously. The head of the bed is elevated to 30 degrees. Prior to administering the medication, the nurse should: (1) elevate the head of the bed to 60 degrees (2) draw blood to determine the phenytoin level after giving the morning dose in order to determine if the client has a toxic blood level (3) stop the tube feeding 1 hour before giving phenytoin and hold tube feeding for 1 hour after giving the medication (4) flush the NGT w 150mL of water before & after giving the phenytoin
Answer: 3 In order for the phenytoin to be properly absorbed and provide maximum benefit to the client, nutritional supplements must be stopped before and after delivery. The head of the bed is elevated to 30 degrees since the client has a tube feeding infusing; it is not necessary to elevate the bed any further. Blood levels are usually drawn before giving a dose of phenytoin, not after. It is not necessary to flush with such a large amount of water (150mL) before and after administering phenytoin.
The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? (1) Maintain a patent airway (2) Record the seizure activity observed (3) Ease the client to the floor (4) Obtain vital signs
Answer: 3, 1, 4, 2 To protect the client from falling the nurse first should ease the client to the floor. It is important to protect the head and maintain a patent airway since altered breathing & excessive salivation can occur. The assessment of the postictal period should include level of consciousness and vital signs. The nurse should record details of the seizure, timing with descriptions of each phase, body parts affected and sequence of involvement, and autonomic signs should be recorded
Which finding will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure? (1) jerking on one extremity that spreads gradually to adjacent areas (2) vacant staring and abruptly ceasing all activity (3) facial grimaces, patting motions, & lip smacking (4) loss of consciousness, body stiffening, & violent muscle contractions
Answer: 4 A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The tonic phase consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction, which lasts about 20 - 30 seconds. The clonic phase involves repetitive movements. The seizure ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts in one region of the cortex and may stay focused on spread (eg jerking in the extremity spreading to other areas of the body). An absence seizure usually occurs in children and involves a vacant start with a brief loss of consciousness that often goes unnoticed. A complex partial seizure involves facial grimacing with patting and smacking
What nursing assessments should be documented at the beginning of the ictal phase of a seizure? (1) HR, RR, pulse ox, & BP (2) last dose of anticonvulsant & circumstances at the time (3) type of visual, auditory, & olfactory aura the client experienced (4) movement of head & eyes & muscle rigidity
Answer: 4 During a seizure, the nurse should note the movement of the client's head and eyes and muscle rigidity, especially when the seizure first beings, to obtain clues about the location of the trigger focus in the brain. Other important assessments would include noting the progression and duration of the seizure, respiratory status, loss of consciousness, pupil size, and incontinence of urine and stool. It is typically not possible to asses the client's pulse and BP during a tonic-clonic seizure because the muscle contractions make assessment difficult to impossible. The last dose of anticonvulsant medication can be evaluated later. The nurse should focus on maintain an open airway, preventing injury to the client, and assessing the onset and progression of the seizure to determine the type of brain activity involved. The type of aura should be assess in the preictal phase of the seizure.
It is the night before a client is to have a CT scan of the head without contrast. The nurse should tell the client: (1) You must shampoo your hair tonight to remove all oil and dirt (2) You may drink fluids until midnight, but after that, drink nothing until the scan is completed (3) You will have some hair shaved to attach the small electrode to your scalp (4) You will need to hold your head very still during the examination
Answer: 4 The client will be asked to hold the head very still during the examination, which lasts about 30 to 60 minutes. In some instances, food and fluids may be withheld for 4 - 6 hours before the procedure if a contrast medium is used because to radiopaque substance sometimes causes nausea. There is no special preparation for a CT scan, so shampoo the night before is not required. The client may drink fluids until 4 hours before the scan is scheduled. Electrodes are not used for a CT scan, nor is the head shaved.
Based on placement in the lungs, what is your first action? (a) call the Rapid Response Team (b) push the NG down farther (c) call the charge nurse (d) call the physician (e) remove the NG
e. remove the NG
To measure the appropriate length prior to insertion you would: measure from the orbit to the tip of the patient's ear, then to the tip of the earlobe and then to the xiphoid process. True or false?
false
The nurse is encouraging self-care in a client who experienced a thrombotic stroke and who now has right-sided hemiparesis. The nurse knows that the best way to accomplish this goal is to place personal hygiene items in which area? (1) on the over bed table on the right side (2) on the over bed table on the left side (3) one foot away from the bed on the right side (4) one foot away from the bed on the left side
(2) on the over bed table on the left side
A client is scheduled for an EEG early in the morning. The nurse working the night shift prior to the procedure should plan to implement which action in the early morning on the day of the test? (1) instruct the client to restrain from washing hair (2) withhold daily dose of AED (3) Place client on NPO status (4) Reinforce client teaching that the test is only mildly uncomfortable
(2) withhold daily dose of AED
Which clinical manifestation is a typical reaction to long-term phenytoin sodium therapy? (1) weight gain (2) insomnia (3) excessive growth of gum tissue (4) deteriorating eyesight
Answer: 3 A common adverse effect of long-term phenytoin therapy is an overgrowth of gingival tissues. Problems may be minimized with good oral hygiene, but in some cases, overgrown tissues must be removed surgically. Phenytoin does not cause weight gain, insomnia, or deteriorating eyesight.
The nurse is assessing a client in the postictal phase of generalized tonic-clonic seizure. The nurse should determine if the client has: (1) drowsiness (2) inability to move (3) paresthesia (4) hypotension
Answer: 1 The nurse should expect a client in the postictal phase to experience drowsiness to somnolence because exhaustion results from the abnormal spontaneous neuron firing and tonic-clonic motor response. An inability to move a muscle part is not expected after a tonic-clonic seizure because a lack of motor function would be related to a complication, such as a lesion, tumor, or stroke, in the correlating brain tissue. A change in sensation would not be expected because this would indicate a complication such as an injury to the peripheral nerve pathway to the corresponding part from the central nervous system. Hypotension is typically not a problem after a seizure
A 21-year-old female client takes clonazepam. What should the nurse ask this client about? (Select All) (1) seizure activity (2) pregnancy status (3) alcohol use (4) cigarette smoking (5) intake of caffeine & sugary drinks
Answer: 1, 2, 3 The nurse should asses the number and type seizures the client has experienced since starting clonazepam monotherapy for seizure control. The nurse should also determine if the client might be pregnant because clonazepam crosses the placental barrier. The nurse should also ask about the client's use of alcohol because alcohol potentiates the action of clonazepam. Although the nurse may want to check on the client's diet or use of cigarettes for health maintenance and promotion, such information is not specifically related to clonazepam therapy
What is the PRIORITY nursing intervention in the postictal phase of a seizure? (1) reorient the client to time, person, & place (2) determine the client's level of sleepiness (3) assess the client's breathing pattern (4) position the client comfortably
Answer: 3 A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of client to time, person, and place. Determining the client's level of sleepiness is useful, but is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent
Normal pH of gastric secretions are: (a) 1-5 (b) 5-7 (c) 6-8 (d) 6-9 (e) > 4
a. 1-5
What are the minimum key points to be documented following an NG insertion? Select all (a) Nare used (b) Size of NG (c) Length left out from nare (measurement) (d) Patient tolerance (e) Connected to suction or clamped (f) Ability of patient to swallow (g) Presence of staff/family when insertion done
a. nare used b. size of ng c. length left out from nare d. patient tolerance e. connected to suction and/or clamped
What types of patients would have an NG? Select all (a) unconscious patient (b) patient with dysphagia (c) patient with severe nausea and vomiting (d) patient with an appendectomy (e) patient with a hip fracture
a. unconscious patient b. patient with dysphagia c. patient with severe nausea and vomiting
Pressure ulcers could occur at the nose, insertion site of the NG. True or false?
true
A nurse is monitoring a client who has sustained a head injury for signs on ICP. The nurse concludes that which vital sign trends are consistent with increasing ICP? (1) increased temp, decreased pulse, increased RR, decreased BP (2) decreased temp, increased pulse, decreased RR, increased BP (3) decreased temp, increased pulse, increased RR, decreased BP (4) increased temp, decreased pulse, decreased RR, increased BP
(4) increased temp, decreased pulse, decreased RR, increased BP
What is the most accurate method of determining NG placement? (a) instilling 20-50 mL of air through the NG and listening at the epigastric area (b) based on EBP the gold standard for the NG, which is radio-opaque, is the XRay (c) instilling 20-50 mL of air through the air vent and listening at the epigastric area (d) observing for the color of the gastric secretions, specifically looking for clear white frothy fluid (e) assessing the patient's lungs and pulse oximetry to be sure the O2 saturation remains above 90%
b. based on EBP the gold standard for the NG, which is radio-opaque, is the XRay
Which of the following actions will make an NG insertion more difficult? (a) Using lubricant (b) Asking the patient to swallow as you are inserting the NG (c) Asking the patient to turn their head away from you during insertion (d) Asking the patient to flex their head to their chest during insertion of the NG
c. Asking the patient to turn their head away from you during insertion
Placement of the anti-reflex valve is which of the following? (a) white to white (main NG port) (b) There is no need to use an anti-reflux valve (c) The blue end of the anti-reflux valve is inserted in to the blue pig-tail of the NG (d) None of the answers listed above are correct
c. The blue end of the anti-reflux valve is inserted into the blue pigtail of the NG
After the insertion of an NG the patient starts to cough, pulse oximetry falls to 78%, and the patient is slightly cyanotic. You suspect that the NG is placed where? (a) in the esophagus (b) the duodenum (c) the facial sinus (d) the lungs
d. the lungs
When preparing to teach a client about phenytoin sodium therapy, the nurse should urge the client not to stop the drug suddenly because: (1) physical dependence on the drug develops over time (2) status epilepticus may develop (3) a hypoglycemic reaction develops (4) heart block is likely to develop
Answer: 2 Anticonvulsant drug therapy should never be stopped suddenly; doing so can lead to life-threatening status epilepticus. Phenytoin sodium does not carry a risk of physical dependency or lead to hypoglycemia. Phenytoin has anti-arrhythmic properties, and discontinuation does not cause heart block
Which instruction should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin? (1) take all medication until it is gone (2) notify the HCP if vision changes occur (3) store gabapentin in the refrigerator (4) take gabapentin with an antacid to protect against ulcers
Answer: 2 Gabapentin may impair vision. Changes in vision, concentration, or coordination should be reported to the HCP. Gabapentin should not be stopped abruptly because of the potential for status epilepticus; this is a medication that must be tapered off. Gabapentin is to be stored at room temperature and out of direct light. It should not be taken with antacids
