HESI: Seizure Disorder Case Study

Two months after being diagnosed with the seizure disorder, Alanna calls the office and tells the nurse that her job's supervisor has informed her that she is going to be let go because of her seizure disorder. Alanna is very upset and tells the nurse that she has been working at the same department store since she was 18-years-old. 15. Which statement reflects that the nurse understands the legal ramifications of the employer's action? - "The Epilepsy Foundation of America will help you keep your job." - "I was afraid this might happen. Legally employers do not have to let you work." - "You should take a copy of your medical records to your employer's personnel office." - "According to the Americans with Disabilities Act, your employer cannot terminate you."

- "According to the Americans with Disabilities Act, your employer cannot terminate you." The 1990 Americans with Disabilities Act states that employers must evaluate an employee's ability to perform the job and may not discriminate on the basis of a disability.

An hour later, Alanna is awake and alert. She does not remember what happened but remembers hearing a buzzing sound. The next thing she remembers is waking up in the emergency department. 22. Which question is most important for the nurse to ask Alanna? - "Why did you quit taking your medication?" - "Have you been taking your medication regularly?" - "Were you under any type of stress the last week?" - "Are you currently on or have you just finished your period?"

- "Have you been taking your medication regularly?" Since the therapeutic Dilantin level is low, the nurse may infer that Alanna has not been taking her medication as prescribed. However, the nurse needs to clarify this inference and then determine the reason before taking further action. It is important to question the client in a non-threatening manner to obtain the needed information, which helps establish a therapeutic relationship.

4. Which of the medical history question(s) should the nurse ask Alanna to determine why the seizure activity started? (Select all that apply.) - "Are you currently taking any type of illegal drugs?" - "Have you ever had any type of head injury?" - "Is there any chance that you may be pregnant?" - "Do you have a history of drinking alcohol?" - "Does anyone in your family have seizure disorders?"

- "Have you ever had any type of head injury?" Head trauma is a possible cause for the new onset of seizure activity. - "Do you have a history of drinking alcohol?" If a client has a history of chronic alcohol use, sudden withdrawal can precipitate seizure activity.

8.Which statement indicates that Alanna understands the client teaching? - "I must brush and floss my teeth after every meal." - "I will have to check my medication level daily." - "My stool may be clay-colored while taking this drug." - "I will not have seizures since I am on this medication."

- "I must brush and floss my teeth after every meal." Gingival hyperplasia is a common occurrence in clients taking Dilantin. Thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care are essential to prevent this complication.

14. Which statement by Alanna indicates that teaching provided by the nurse has been effective? - "I should move back home with my parents." - "I will carry a Medic Alert band at all times." - "I do not think that I need to go to any support groups." - "It is important for my family to get checked for epilepsy."

- "I will carry a Medic Alert band at all times." Alanna should carry a band or card at all times so her medical condition will be easy to identify.

Alanna responds to the nurse's questions and then tells the nurse that someone has been talking to her about seizures and asked her if she had aura with her seizure. She asks the nurse, "What is an aura?" 5. Which response by the nurse is correct? - "It is a visual or auditory warning that the seizure is about to start." - "Auras occur when you are physically and physiologically exhausted." - "If you had an aura you would know what it is." - "Auras do not occur with the type of seizures that you are having."

- "It is a visual or auditory warning that the seizure is about to start." An aura is a visual, auditory, or olfactory occurrence that occurs prior to a seizure and warns the client that the seizure is about to occur. The aura often allows time for the client to fall to the floor or find a safe place to have the seizure.

Another member of the group asks if there are any activities that should be avoided. 18. How should the nurse respond? - "Mountain climbing is an example of an activity to avoid." - "It really depends on how well your epilepsy is controlled." - "As long as safety gear is worn you can do any activity." - "Epileptics should not participate in any contact sports."

- "It really depends on how well your epilepsy is controlled." If seizures are well-controlled, there are no specific contraindications to any activity. However, if seizures are still occurring it is probably advisable to avoid some sports and activities.

17. Which statement is the nurse's best response? - "Research shows that cold water causes seizures more than warm water." - "Someone who knows what to do if you have a seizure should be with you." - "Before attempting to go swimming, you should consult with your healthcare provider." - "Swimming is one activity that people with epilepsy should plan to avoid."

- "Someone who knows what to do if you have a seizure should be with you." The Epilepsy Foundation states there is no reason why people with epilepsy should not participate in swimming as a leisure activity; however, it is recommended that a swimming partner be present who is knowledgeable about what to do during a seizure.

Alanna's primary nurse realizes that Alanna is of the Jewish faith and wants to provide culturally sensitive nursing care during her hospitalization. 25. Which statement reflects that the nurse is sensitive to Alanna's cultural needs? - "No one will interrupt you during Friday morning prayers." - "The hospital chaplain will come visit you every day." - "Tell me about the type of Jewish teachings you practice." - "You can be moved to a room with another Jewish person."

- "Tell me about the type of Jewish teachings you practice." Many people of the Jewish faith practice different teachings, some more Orthodox and some more progressive. Therefore, the nurse needs to know about Alanna's practices to help meet her cultural needs.

24. How should the nurse respond? - "The most important thing is to keep her from injuring herself." - "I know you would do the best that you could for your daughter." - "It helps if you restrain her arms so that she won't flail about." - "You should make sure she takes her medication every day."

- "The most important thing is to keep her from injuring herself." Nothing can stop the seizure once it starts. Protecting the client from injury is the most important action to take.

Alanna appears overwhelmed with all the information the neurologist discussed with her. She tells the nurse, "I don't understand why the neurologist is ordering an MRI." 7. Which statement by the nurse is the best response? - "The test will rule out many possible causes of seizures." - "An MRI can help determine the focal origin of the seizure." - "This test will identify elevated protein levels in the brain." - "It will confirm the seizure diagnosis and localize the lesion."

- "The test will rule out many possible causes of seizures." An MRI can determine the presence of any of the following potential causes of the seizures: a tumor, congenital lesions, an edema, an infarct, a hemorrhage, an arteriovenous malformation, or a structural deviation.

10. Which response by the nurse is most therapeutic? - "You should contact the Epilepsy Foundation. I think it will help." - "This is all new to you, and you must be frightened. Let's talk for awhile." - "Because you don't feel bad doesn't mean you won't have a seizure." - "I know seeing someone having a seizure is a frightening experience."

- "This is all new to you, and you must be frightened. Let's talk for awhile." The nurse acknowledges Alanna's feelings and encourages her to continue to ventilate her feelings.

While talking on the phone, Alanna asks the nurse about driving her car. She states that she has not been driving due to the medications but hasn't had a seizure in 2 months and is not drowsy. She asks if she can start driving her car. 16. How should the nurse respond? - "You need to contact the Department of Transportation to find out the state laws." - "You should not drive your car. Can't you keep taking the bus or train?" - "I don't think you would want to be responsible for causing a car accident." - "I want you to make an appointment to come see me and we can talk."

- "You need to contact the Department of Transportation to find out the state laws." Each state has laws concerning individuals with a seizure disorder having a driver's license. Some states will allow a driver's license after being seizure free for 6 months to 2 years. Many states require letters from the physician or nurse practitioner.

19. If the nurse believes in the ethical principle of veracity for the client, how should the nurse respond? - "I would recommend waiting until it becomes more serious." - "That is a hard question to answer. I am not sure I know the right answer." - "You should tell him the truth on the first date so he will know." - "You are worried about how to tell your boyfriend you have epilepsy?"

- "You should tell him the truth on the first date so he will know." Veracity is truth-telling, and it is reflected by this response.

Alanna tells the nurse that she was on her "period" or getting ready to start her "period" both times she had a seizure. She shares with the nurse that she is really worried about having a seizure the next time she menstruates. 13. How should the nurse respond? - "You are concerned about having a seizure when you start your period." - "Are you currently taking any type of birth control pill or using the patch?" - "Your menstrual cycle can cause seizure activity due to hormone levels." - "The menstrual cycle does not usually affect your seizure activity."

- "Your menstrual cycle can cause seizure activity due to hormone levels." The onset of menstruation can cause seizure activity due to increased hormone levels that alter the excitability of neurons in the cerebral cortex. The client should be instructed to keep a record to determine if this pattern continues.

The nurse continues to teach Alanna about the newly prescribed anticonvulsant medication. 9. Which instruction should the nurse include in the teaching session? - Decrease alcohol intake while taking this medication. - Take the medication with milk or milk products. - Notify the office if experiencing muscle uncoordination. - Avoid hazardous tasks until the drug has been regulated.

- Avoid hazardous tasks until the drug has been regulated. These medications may cause drowsiness, decreased mental alertness, and dizziness at first. With continued therapy these symptoms usually disappear or the dose may have to be changed.

Prior to Alanna's discharge the nurse evaluates the client teaching provided during this hospitalization. 28. Which client teaching goal is most important to determine Alanna's understanding? - Agree to attend support group meetings regularly. - Have no seizure activity for the next 6 months. - Describe five strategies to prevent seizure activity. - Demonstrate how to correctly take her medication.

- Describe five strategies to prevent seizure activity. A correct description of the needed information is the best way to evaluate if teaching was effective. Remember goals must be measurable. Stating the correct dosage, side effects, when to call the healthcare provider, and the importance of follow-up visits are appropriate goals when evaluating the effectiveness of client teaching.

Alanna's serum phenytoin (Dilantin) level is 7 mcg/mL. She has intravenous fluids of 5% Dextrose in Water (D5W) infusing at 100 mL/hour in the left forearm. The emergency department physician prescribes phenytoin (Dilantin) 25 mg intravenous push. 21. Which action should the nurse implement? - Question the prescription since 7 mcg/mL is above the therapeutic level. - Dilute the medication and flush the tubing before and after with normal saline. - Administer the medication undiluted in the port closest to the intravenous site. - Determine the time when Alanna took the last oral dose of her Dilantin.

- Dilute the medication and flush the tubing before and after with normal saline. Dilantin is not compatible with any fluid except normal saline; the nurse should flush the IV before and after with normal saline only.

Alanna is discharged from the hospital after 2 days. Her Dilantin level is 10.4 mcg/mL after she has received intravenous Dilantin. Alanna's neurologist is changing Alanna's anticonvulsant from Dilantin to valproic acid (Depakote) to reduce possible side effects and increase her compliance with medication administration. 27. Which action should the nurse include when providing discharge teaching regarding the new medication? - Explain to the client that many clients get a rash that will go away with time. - Advise the client that, unlike Dilantin, drug levels will not need to be checked. - Instruct the client to take this medication on an empty stomach to help with absorption. - Discuss with the client the importance of having liver function tests while on this medication.

- Discuss with the client the importance of having liver function tests while on this medication. This medication is heptotoxic so liver function tests are monitored at follow-up visits.

20. Which intervention should the nurse implement first? - Assess the client's vital signs. - Obtain a serum phenytoin (Dilantin) level. - Ensure suction equipment is at the bedside. - Apply a cardiac telemetry monitor.

- Ensure suction equipment is at the bedside. The client will be very tired and will want to sleep after a seizure. Maintaining a patent airway is the priority. Suction equipment should be available in case the client aspirates or starts choking. Remember Maslow's Hierarchy of Needs. Airway is always first.

Alanna shares that she is worried about being able to have children. She doesn't have a boyfriend right now but someday wants to get married and raise a family. 11. The nurse's response should be based on which scientific rationale? - Research shows that women with epilepsy have a more difficult time conceiving. - Anticonvulsant therapy is contraindicated in pregnancy. - Epilepsy does not prevent women from having children. - Genetic counseling is needed for women with epilepsy.

- Epilepsy does not prevent women from having children. Alanna will need preconception counseling when considering child birth. She will require special care and guidance before, during, and after pregnancy.

6. Which action should the nurse include in preparing Alanna for the EEG? - Advise the client not to eat anything for 12 hours prior to the procedure. - Instruct the client to refrain from consuming caffeine prior to the EEG. - Explain that there will be some discomfort during the procedure. - Determine if Alanna has any allergies to iodine or shellfish.

- Instruct the client to refrain from consuming caffeine prior to the EEG. Ingestion of caffeine will cause a stimulating effect to the brain.

Education is the key to treating epilepsy. The office nurse teaches Alanna about how to reduce the incidence of seizure activity and how to promote safety during a seizure. 12.Which health promotion activity should the nurse discuss with Alanna? - Take tub baths rather than showers. - Be sure to exercise outside rather than in a gym. - Learn to identify seizure triggers. - Take an anticonvulsant when an aura occurs.

- Learn to identify seizure triggers. Factors that may trigger seizures are abrupt withdrawal from medication, constipation, fatigue, fever, and sounds and sights such as television, flashing videos, and computer screens.

After initial interventions are implemented, the man continues to have a tonic-clonic seizure. 2. What action should the nurse implement next? - Insert an oral airway into the client's mouth. - Determine if the client is incontinent of urine. - Note the time, duration, and type of seizure. - Notify the neurologist of the client's seizure.

- Note the time, duration, and type of seizure. Accurate assessment by the nurse during the seizure provides important data used in determining the area in which focal activity originates, the area of the brain involved, and the type of seizure. It is important to document whether the beginning of the seizure was observed.

23. Which intervention should the nurse implement? - Ask if she wants her parents in the room. - Pad and elevate the side rails of Alanna's bed. - Place a padded tongue blade at the bedside. - Attach a seizure precautions sign to the door.

- Pad and elevate the side rails of Alanna's bed. Alanna is at high risk for injury because of her recent seizure activity. Protecting her from injury by elevating and padding the side rails helps address Alanna's safety needs.

Alanna later tells the nurse that she and her family follow a kosher diet. The next morning, Alanna's parents arrive at the nurses' station with a kosher breakfast for Alanna, which includes a bagel, scrambled eggs, and a glass of orange juice. Alanna has no prescribed dietary restrictions. 26. What action should the nurse take? - Inform Alanna's parents that it would be better if they allowed their daughter to eat the food cooked by the hospital. - Exchange the food provided on the hospital tray with the kosher food and deliver the tray to Alanna's room. - Return the tray provided by the hospital and ask the parents if they would like to take the meal they provided to Alanna's room. - Offer to order additional guest trays from the hospital kitchen so that Alanna's parents can eat with her.

- Return the tray provided by the hospital and ask the parents if they would like to take the meal they provided to Alanna's room. This action supports Alanna's cultural food preferences, while also ensuring that the kosher foods do not come in contact with non-kosher foods and are not inadvertently served on dinnerware used for non-kosher foods.

After the man's seizure activity stops he is moved to a private room. The client had a 3-minute seizure, has no apparent injuries, and is oriented to name, place, and time but is very lethargic. 3. Which intervention should the nurse implement? - Perform a complete neurological assessment. - Transfer the client to the emergency department. - Turn the client to the side, and allow him to sleep. - Interview the client to find out what caused the seizure.

- Turn the client to the side, and allow him to sleep. During the postictal phase the client is very tired and should be allowed to rest quietly and sleep; placing the client on the side will help maintain a patent airway and prevent aspiration. Once the gentleman with the seizure is taken to the private room, the other people are brought back into the waiting room. Alanna sits down and after 20 minutes is called back to the neurologist's office.

A man sitting across from Alanna starts having a seizure. His entire body is rigid, his arms and legs are contracting and relaxing, and he is making guttural sounds. Alanna yells for the nurse, who immediately comes into the waiting room. 1. Prioritize the nursing actions in order from first action through last action. 1. Push the furniture away from the client. 2. Remove people from the waiting room. 3. Assess the client's blood pressure. 4. Safely move the client to the floor.

1. Safely move the client to the floor. 2. Push the furniture away from the client. 3. Remove people from the waiting room. 4. Assess the client's blood pressure.

Alanna, her roommate, and her parents decide to attend an epileptic support group meeting that is held monthly at the local hospital. The topic for tonight is leisure activity and living with epilepsy.

A clinical nurse specialist is the guest speaker for the group. One of the group members asks the nurse, "Is it okay for me to swim at the local YMCA?"

Alanna tells the nurse the medication just made her feel funny and she really didn't think she would have any more seizures, so she quit taking it 2 weeks ago. Alanna is admitted into the hospital for observation.

Alanna is admitted to the medical unit, and her parents arrive a few minutes later. She is drowsy but arouses easily to verbal stimuli.

The new anticonvulsant, Depakote, does not make Alanna feel funny and she takes it faithfully. She continues to work as a sales clerk, plans to graduate from college next semester, and remains active in the Shalom Synagogue.

Alanna, her roommate, and her parents attend the monthly Epilepsy Support Group at the local hospital.

Three weeks after the phone call to the office nurse, Alanna is transported to the emergency department by an ambulance, accompanied by her roommate. Her roommate states, "She was watching television and had a seizure.

As soon as the first seizure stopped, she started having another seizure, so I called 911." Alanna is lying on the stretcher with her eyes closed, but there is no seizure activity at this time.

The nurse asks Alanna why she has been referred. Alanna reports that 2 weeks ago her roommate found her passed out on the floor. Alanna states she could not remember what happened but thought it might be because she had not been eating right. Then, last week Alanna's roommate found her making unusual sounds and noticed that her arms and legs were jerking.

At that time she was taken to the emergency department. She has her emergency room records and her past history medical records from her family healthcare provider.

During the teaching session, Alanna shares with the nurse that she is very scared because she really doesn't remember having the seizure.

She states that she had never seen someone with a seizure until the other day in the neurologist's office. Illness has never been part of her life, and she doesn't feel sick now.

Alanna's mother tells the nurse that neither she nor Alanna's father have ever seen Alanna have a seizure. They have read all the information on epilepsy and have talked to Alanna and the neurologist about the seizures but are very worried about their daughter.

The mother tells the nurse, "I don't think I would know what to do if I saw her have a seizure."

The neurologist informs Alanna that no brain tumor, infection, or trauma was found but she did have seizure brain wave activity during the EEG. This brain activity is indicative of epilepsy.

The neurologist prescribes phenytoin (Dilantin), an anticonvulsant, to help prevent the seizure activity. The clinic nurse teaches Alanna about the medication, its side effects, and the need to take it every day.

Alanna tells the nurse she remembers hearing a buzzing sound, and then the next thing she knew someone was waking her up. The neurologist comes into the room and completes Alanna's history and physical along with the nurse. With Alanna's history, the neurologist thinks that Alanna has had seizure activity and wants to determine exactly what is causing the new onset of seizure activity.

The neurologist schedules Alanna for an electroencephalogram (EEG) and a magnetic resonance image (MRI) to help evaluate Alanna's seizure disorder. The nurse discusses the tests with Alanna.

The group leader shares that participation in any leisure activity requires weighing the risks against the benefits that the activity provides. Safety of the individual with epilepsy as well as the others participating in the activity is of the utmost importance.

When the group meeting is over, Alanna privately asks the nurse, "When is the best time to tell a potential boyfriend I have a seizure disorder?"