Seizures

What is the nursing action of highest priority to be taken with a patient who experiences a generalized tonic/clonic seizure? 1. Restraining the arms and legs 2. Controlling head movement 3. Protecting the head and extremities 4.Inserting a tongue blade between the teeth

3. Protecting the head and extremities Staying with the patient to provide protection of the head and extremities is the most important nursing care activity for a patient experiencing a generalized tonic/clonic seizure. Attempting to restrain or control the jerking movement of the head and extremities during a seizure may cause further injury and even fracture bones. Body parts should not be restrained or controlled. Use of a tongue blade is not acceptable in current practice because it is difficult to insert once the seizure begins and the patient may bite through the tongue blade and aspirate.

A nurse is providing discharge instructions to a female client who has a prescription for phenytoin (Dilantin). Which of the following information should the nurse include? A. Consider taking oral contraceptives when on this medication. B. Watch for receding gums when taking the medication C. Take the medication at the same time every day D. Provide a urine sample to determine therapeutic levels of the medication.

C. Correct-The nurse should instruct the client to take take phyentoin at the same time every day to enhance effectiveness A . Client should not take oral contraceptives because phyentoin decreases its effectiveness B. Phyentoin causes overgrowth of gums C. The client should have periodic blood tests to determine therapeutic levels.

Describe an absence seizure

An absence seizure usually occurs in children and involves a vacant stare with a brief loss of consciousness that often goes unnoticed.

What are partial (focal) seizures?

Begin in part of one cerebral hemisphere Most often in adults two classes: simple and complex

Seizures occur during this phase

Ictal phase

What is status epilepticus?

It is prolonged seizure activity occurring over a 30 minute period.

What are the six generalized seizures?

Tonic-Clonic- Absence myoclonic tonic clonic atonic

This seizure phase is characterized by the rest and recovery phase and may include the patient sleeping for days.

postictal phase

How long do patients lose consciousness during a generalized seizure?

seconds to minutes

The signs and symptoms of the aural phase can include:

skins sensations unusual smells visual changes with light

The patient with type 1 diabetes mellitus with hypoglycemia is having a seizure. Which medication should the nurse anticipate administering to stop the seizure? 1. Intravenous (IV) dextrose solution 2. IV diazepam (Valium) 3. IV phenytoin (Dilantin) 4. Oral carbamazepine (Tegretol)

1 intravenous (IV) dextrose solution This 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 sees a client walking in the hallway who begins to have a seizure. The nurse should do which of the following in priority order? 1. Maintain patent airway 2.record the seizure activity observed 3.ease the client to the floor 4. Obtain vital signs

3.ease the client to the floor 1. Maintain patent airway 4. Obtain vital signs 2.record the seizure activity observed

A 22 year old who hit his head while playing football has a tonic-clonic seizure. Upon wakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than age 20? A. Head trauma B. Electrolyte imbalance C. Congenital defect D. Epilepsy

A. Trauma is one of the primary causes of brain damage and seizure activity in adults. Other common causes of seizure activity in adults include neoplasms, withdrawal from drugs and alcohol, and vascular disease.

Which seizure phase occurs minutes before the seizure?

Aural phase

Which of the following should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin (Neurontin)? A. Take all the medication until it is gone B. Notify the physician if vision changes occur C. Store gabapentin in the refrigerator D. Take gabapentin with an antacid to protect against ulcers

B. gabapentin (Neurontin) may impair vision. Changes in vision, concentration, or coordination should be reported to the physician. Gabapentin should not be stopped abruptly because of the potential for status epilepticus; this medication must be tapered off. Gabapentin is stored at room temperature and out of direct light. It should not be taken with antacids.

Auras are typical of A. Primary GTCS B. Absence seizures C. Myoclonic seizures D. Partial seizures

D. Partial seizures

Seizures may be identified by A. Jerking movements over entire body B. Staring C. Loss of awareness D. Arm or leg jerking E. All of the above

E. All of the above

When the entire brain is involved in a seizure, this is what type of seizure?

a generalized seizure

Describe a complex partial seizure

involves facial grimacing with patting and smacking

The parent of a child newly diagnosed with a typical absence seizure is worried. What information should the nurse provide to the parent regarding typical absence seizures? Select all that apply. 1. The occurrence of seizures usually subsides during adolescence. 2. The seizures are characterized by brief staring spells. 3. The seizures are usually precipitated by flashing lights. 4. A seizure is associated with loss of postural tone. 5. The child will usually seem confused after a seizure

1, 2. 3

Which characteristic of a patient's recent seizure is consistent with a focal seizure? 1. The patient lost consciousness during the seizure. 2.The seizure involved lip smacking and repetitive movements. 3. The patient fell to the ground and became stiff for 20 seconds. 4. The etiology of the seizure involved both sides of the patient's brain

2. 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.

Which of the following will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure? A. Jerking in one extremity that spreads gradually to adjacent areas B. Vacant staring and abruptly ceasing all activity C. Facial grimaces, patting motions, and lip smacking D. Loss of consciousness, body stiffening and violent muscle contractions

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 20 to 30 seconds. The clonic phase involves repetitive movements. The seizure ends with confusion, drowsiness, and resumption of respiration

A patient arrives to the nurse practitioner because he was walking to his car when he suddenly lost muscle tone and fell to the ground. He lost consciousness but regained it upon hitting the ground but came to be examined just to be safe. With these symptoms, what type of seizure did the patient have?

An atonic seizure

A client who has had seizures asks the nurse about being able to drive because of the seizures. Which response by the nurse is best? A. A person with a history of seizures can drive only during daytime hours B. A person with evidence that the seizures are under medical control can drive C. A person with evidence that seizures occur no more than every 12 months can drive D. A person with a history of seizures can drive if he or she carries a medical identification card

B. Specific motor vehicle regulations and restrictions for people who experience seizures vary locally. Most commonly, evidence that the seizures are under medical control is required before the person is given permission to drive. The typical amount of time a person must be seizure free to drive is two years.

What is the priority nursing intervention in the postictal phase of a seizure? A. Reorient the client to time, person, and place B. Determine the client's level of sleepiness C. Assess the client's breathing pattern D. Position the client comfortably

C. A priority for the client in the postictal phase 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.

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? A. Maintain the client on bed rest B. Administer butabarbital sodium 30 mg PO three times a day C. Close the door to the room to minimize stimulation D. Administer carbamazepine 200 mg PO twice per day

D. Administer carbamazepine 200 mg PO Carbamazepine is an anticonvulsant that helps prevent further seizures

Which is a specific investigation of diagnosing seizure disorder? A. EMG B. EOG C. ECT D. ERP E. EEG

E. EEG

What is a complex partial seizure?

LOC or blackout for 1-3 minutes Automatisms (client not aware); lip smacking, patting, picking at clothes After seizure may experience amnesia Area of brain most often involved; temporal lobe

What are unclassified or idiopathic seizures?

Occur for no known reason account for half of all seizure activity do not fit into generalized or partial classifications

During a status epilepticus seizure which intervention would be the highest priority? A. administers lorazepam (Ativan) B. Perform ECG monitoring C. Maintain a patent airway D. Establish IV access E. Review ABG results

You would do all of the interventions listed but the highest priority would be C. Maintain a patent airway

A myoclonic seizure is characterized by what?

a sudden, excessive jerk of the body or extremities. The jerk may be forceful enough to hurl the person to the ground. These seizures are brief and may occur in clusters

The Tonic phase of a seizure involves:

stiffening or rigidity of the muscles (arms/legs) - last about 10-20 sec - followed by loss of consciousness

An atonic ("drop attack") seizure involves what?

either a tonic episode or a paroxysmal loss of muscle tone and begins suddenly with the person falling to the ground. Consciousness usually returns by the time the person hits the ground, and normal activity can be resumed immediately. Patients with this type of seizure are at a great risk of head injury and often have to wear protective helmets.

A 50-year-old male patient has been diagnosed with amyotrophic lateral sclerosis (ALS). What nursing intervention is most important to help prevent a common cause of death for patients with ALS? 1. Reduce fat intake 2.Reduce the risk of aspiration 3.Decrease injury related to falls 4.Decrease pain secondary to muscle weakness

2. Reduce the risk of aspiration Reducing the risk of aspiration can help prevent respiratory infections that are a common cause of death from deteriorating muscle function. Reducing fat intake may reduce cardiovascular disease, but this is not a common cause of death for patients with ALS. Decreasing injury related to falls and decreasing pain secondary to muscle weakness are important nursing interventions for patients with ALS, but are unrelated to causes of death for these patients.

What nursing assessments should be documented at the beginning of the ictal phase of a seizure? A. Heart rate, respirations, pulse oximeter, and BP B. Last dose of anticonvulsant and circumstances at the time C. Type of visual, auditory, and olfactory aura the client experienced D. Movement of the head and eyes and muscle rigidity

D. During a seizure, the nurse should note movement of the client's head and eyes and muscle rigidity, especially when the seizure first begins, to obtain clues about the location of the trigger focus in the brain

It is the night before a client is to have a CT scan of the head without contrast. The nurse should tell the client: A. You must shampoo your hair tonight to remove all oil and dirt B. You may drink fluids until midnight but after that drink nothing until the scan is completed C. You will have some hair shaved to attach the small electrode to your scalp D. You will need to hold your head very still during the examination

D. You will need to hold your head very still during the examination

Absence seizures (generalized) are:

breif seizures/lasts seconds - may/may not lose consciousness - no loss/change in muscle tone - may occur several times a day - pt appears to be daydreaming - most common in children

A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? Select all that apply _____A. Overwhelming fatigue should be avoided _____B. Caffeinated products should be removed from the diet _____C. Looking at flashing lights should be limited _____D. Aerobic exercise may be performed _____E. Episodes of hypoventilation should be limited _____F. Use of aerosol hairspray is recommended

A. Correct The nurse should instruct the client to avoid overwhelming fatigue, which may trigger a seizure by stimulating abnormal electrical neuron activity B. Correct Caffeinated products may trigger a seizure by stimulating abnormal electrical neuron activity C. Correct Flashing lights can trigger seizures D. Incorrect The client should decrease physical activity to avoid seizures E. Excess hyperventilation may trigger a seizure F. Aeorosol hairsprays may trigger a seizure

A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? A. Keep the client in a side-lying position B. Monitor the client's vital signs C. Reorient the client to the environment D. Check the client for injuries

A.Keep the client in a side-lying position

Seizures can be related to what?

Withdrawal from alcohol Withdrawal from antiepileptic medication infection fever

A patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. What should the nurse immediately assess the patient for? 1. an aura or focal seizure 2.Nystagmus or confusion 3.Abdominal pain or cramping 4.Irregular pulse or palpitatons

2. Nystagmus or confusion Diplopia is a sign of phenytoin toxicity. The nurse should assess for other signs of toxicity, which include neurologic changes, such as nystagmus, ataxia, confusion, dizziness, or slurred speech. An aura, focal seizure, abdominal pain or cramping, irregular pulse, or palpitations are not associated with phenytoin toxicity.

What instructions should a nurse give to a patient who has focal seizures well controlled with phenytoin (Dilantin) and who has mild gingival hyperplasia? Select all that apply. 1. The drug should be changed immediately. 2. Regular flossing can control gingival tissue growth. 3. Surgical repair of gingival tissue will be required. 4. Regular tooth brushing can limit hyperplasia. 5. Gingival hyperplasia is not related to phenytoin (Dilantin).

2. Regular Flossing can control gingival tissue growth 4. Regular tooth brushing can limit hyperplasia Gingival hyperplasia is a common side effect of phenytoin (Dilantin). The nurse should instruct the patient to maintain good dental hygiene with regular tooth brushing and flossing. Regular flossing not only helps in maintaining good dental hygiene but also helps control gingival tissue growth. Similarly, regular brushing, besides being generally good for dental health, also helps limit gingival hyperplasia. Mild gingival hyperplasia does not require the drug to be replaced. Surgical intervention would be required only if the gingival hyperplasia were extensive, which is not the case with this patient.

The client will have an EEG in the morning. The nurse should instruct the client to have which of the following 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

3. Beverages containing 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 does not need to be on a liquid diet or NPO

The nurse assesses a patient for signs of petit mal or absence seizures. What is the classic sign of this seizure disorder? 1. Dizziness 2. Intense anxiety 3.Stiffening of the body 4.Vacant facial expression

4 Vacant facial expression The patient experiencing a petit mal or absence seizure displays a sudden vacant look and usually stares straight ahead. This type of seizure often goes unnoticed by the patient or others. Dizziness and intense anxiety are not commonly associated with petit mal or absence seizures. Stiffening of the body is the tonic phase and is associated with a tonic-clonic seizure, not absence seizure.

A patient with a history of epilepsy is in the postanesthesia recovery unit (PACU) after surgery under local anesthesia. The patient has a tonic-clonic seizure that lasts two minutes. Which action should the nurse take while the patient is having the seizure? 1. Restrain the patient to prevent injury. 2. Administer 50 grams of dextrose intravenously. 3.Reorient the patient to place and time. 4. Ensure the patient has a patent airway

4. Ensure the patient has a patent airway During a tonic-clonic seizure the patient becomes unconscious, has generalized stiffening (tonic phase), and then jerking (clonic phase). The most important nursing intervention is to maintain the patient's open airway. Suctioning equipment should be available. The patient should not be restrained but protected from injury. Intravenous dextrose is not indicated because the patient is not noted to be hypoglycemic. Reorientation is not done with the patient unconscious during the seizure.

Describe a partial seizure.

A partial seizure starts in one region of the cortex and may stay focused or spread (eg. jerking in the extremity spreading to other areas of the body).

A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? Select all that apply. _____A. Provide Privacy _____B. Ease the client to the floor if standing _____C. Move furniture away from the client _____D. Loosen the client's clothing _____E. Protect the client's head with padding _____F. Restrain the client

A. Correct. The nurse should implement privacy to minimize client's embarrassment B. Correct The nurse should ease the client to the floor to prevent falling C. Correct. Move furniture away to prevent injury D. Correct Loosening of clothes minimizes restriction of movement E. Correct This protects the client's head from injury by placing the client's head in the nurse's lap or using a pillow or blanket under the head during a seizure

The nurse is assessing a client in the postictal phase of generalized tonic-clonic seizure. The nurse should determine if the client has: A. drowsiness B. Inability to move C. Parasthesia D. Hypotension

A. Drowsiness 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.

Which of the following is the most priority nursing diagnosis in a patient with seizure disorders? A. Risk for injury related to seizure activity B. Fear related to the possibility of seizures C. Ineffective individual coping related to stresses imposed by epilepsy D. Deficient knowledge related to epilepsy and its control

A. Risk for injury related to seizure activity

Which of the following is contraindicated for a client with seizure precautions? A. Encouraging him to perform his own personal hygiene B. Allowing him to wear his own clothing C. Assessing his oral temperature with a glass thermometer D. Encouraging him to be out of bed

C. Assessing his oral temperature with a glass thermometer

A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following information should the nurse include in the teaching? A. The use of microwave to the heat food is permitted B. Inform the provider to order only an MRI when a scan is needed C. Place a magnet over the implantable device when an aura occurs D. The use of ultrasound diathermy for pain management is recommended

C. Correct: The client should be instructed to hold a magnet over the implantable device when an aura occurs so as to decrease seizure activity A. Incorrect: The client should be instructed to avoid using a microwave, which may affect the stimulator B. Incorrect: The client should be instructed to inform his providers about the stimulator, which would be affected if an MRI were performed. D. Incorrect: The client should be instructed to avoid the use of the ultrasound diathermy for pain management because of its effect on the stimulator

The client is scheduled to receive phenytoin (Dilantin) through a nasogastric 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: A. Elevate the head of the bed to 60 degrees B. Draw blood to determine the Dilantin level after giving the morning dose in order to determine if client has toxic blood level C. Stop the tube feeding 1 hour before giving Dilantin and hold tube feeding for 1 hour after giving Dilantin D. Flush the NGT with 150 ml of water before and after giving the Dilantin

C. In order for Dilantin 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 30 degrees since this 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 dilantin, not after. It is not necessary to flush with such large amounts of water before and after Dilantin