Seizure Pearson NCLEX 11-2
The nurse is teaching a client about possible seizure triggers. Which information should the nurse include? (Select all that apply.) A. Specific odors B. Flashing lights C. Menstruation D. Lactose consumption E. Fever
A, B, C, E Rationale: There are many triggers reported by clients that elicit seizure activity. Commonly reported triggers include menstruation, flashing lights (such as strobe lights), and odors (such as a specific perfume). Fever can trigger a seizure. With a fever, it is not necessarily the temperature itself but how fast the temperature rises that triggers the seizure. Consumption of milk products has not been reported as a common trigger for seizure activity.
The nurse is caring for a client with a seizure disorder currently controlled with antiseizure medication. The client states, "A friend recommended an herbal supplement for my depression. Can I take it?" Which response by the nurse is correct? A. "St. John's wort has been known to decrease the effectiveness of your antiseizure medication." B. "You can take valerian along with your antiseizure medication to help you sleep." C. "You should avoid garlic, because it can decrease the effectiveness of your antiseizure medication." D. "Essential oils would be a better option with your antiseizure medication."
Answer: A Rationale: Clients whose seizures are controlled with antiseizure medication should avoid herbal preparations, especially St. John's wort, as it can decrease the effectiveness of some anitconvulsive medications. Clients who regularly use essential oils should be cautioned that many essential oils can trigger seizures. Valerian can increase the sedative effect of some medications and should be avoided. Garlic can possibly increase the antiseizure medication levels and should be avoided.
Medication has been ineffective in controlling a client's seizures. Which treatment option should the nurse suspect will be discussed with the client? A. Surgical resection B. Herbal remedies C. More sleep D. Head massage
Answer: A Rationale: Intractable seizures occur in 30% of clients with a seizure disorder. Surgery will be considered if the area of seizure focus (where the seizure activity starts) can be identified and is not responsible for any critical functions such as movement, sensation, or speech. Although getting more sleep and having a head massage are relaxation methodologies, they are not treatments for intractable seizures. Herbal remedies have the tendency to increase or decrease the effectiveness of antiseizure medication and are not recommended for clients with seizure disorder.
A client asks the nurse what might trigger a seizure. Which situation should the nurse include in the response? A. Exposure to toxins B. Decreased intracranial pressure C. Low body temperature D. Low blood pressure
Answer: A Rationale: The cause of seizures is unknown in up to 70% of those diagnosed with seizure disorder. However, they can occur after exposure to toxins. High blood pressure, not low, is associated with increased risk for stroke, which may be associated with the development of seizure disorder. Fever, not low body temperature, and increased, not decreased, intracranial pressure are also associated with the development of seizure disorder.
A 50-year-old client with a newly diagnosed seizure disorder is depressed because they are not allowed to drive and have lost their independence. Which question should the nurse ask to support the client? (Select all that apply.) A. "What does being able to drive mean to you?" B. "How is not being able to drive affecting you?" C. "Who is supporting you during this transition?" D. "Do you have someone who can drive you to appointments?" E. "What kind of alternate transportation are you using?"
Answer: A, B, C, E Rationale: Open-ended questions that allow the client to express their feelings about what is happening open up the conversation, so the nurse can learn more about the client's options and support system. A yes or no question can close down communication, and the client needs transportation for more than just getting to appointments.
The nurse is planning discharge teaching for a 30-year-old female client who was newly diagnosed with tonic-clonic seizures. Which information should the nurse include in this teaching plan? (Select all that apply.) A. Wearing a bracelet that provides health information B. Avoiding driving while taking antiseizure medication C. Keeping a padded tongue blade at home in case of a seizure D. Taking showers rather than tub baths E. Monitoring the menstrual cycle
Answer: A, B, D, E Rationale: A bracelet with health information is an important piece of information in case the client becomes unconscious and there is no one around who knows the client's health history. The client will be on antiseizure medication for life. The client must not stop taking medications in order to drive. There is a safety risk of drowning with being in water during a seizure. The client would be safer in a shower than in several inches of water. Bystanders and family members should not place anything in the client's mouth during a seizure. This could obstruct the client's airway. The client's head should be turned to the side. There is a relationship between menses and an increase in seizures. The client may need to increase medications and avoid triggers during this time each month.
The nurse is admitting a client with a history of frequent tonic-clonic seizures. Which information would be most valuable for the nurse to obtain when performing the health history assessment? (Select all that apply.) A. Presence of auras B. Incontinence during seizure C. Triggers for seizures D. Age of seizure onset E. Duration of seizures
Answer: A, C, D Rationale: The nurse will need information about triggers to provide safe and effective care for the client. The client must not be exposed to known triggers. The nurse would ask the client at what age the seizures began. This will let the nurse know how many years the client has had seizure disorder. The nurse would ask about auras. This information helps the nurse to assess for potential seizure activity. The duration of seizures may vary. The client will not be able to give an accurate answer to this question. Incontinence during a seizure is an expected finding. This information will not provide valuable information in the care of this client
The nurse is caring for a client who is newly diagnosed with a seizure disorder. The nurse should anticipate which diagnostic test to be prescribed? (Select all that apply.) A. Urine culture B. Thyroid panel C. Blood chemistry D. Lumbar puncture E. Complete blood count
Answer: A, C, D, E Rationale: Diagnostic tests that may be ordered for clients who are experiencing seizures include a complete blood count and blood chemistry (to identify conditions such as infections, anemia, or diabetes that may be triggering the seizures), urine culture (to rule out infection), and a lumbar puncture for cerebrospinal fluid (CSF) examination (in clients in whom meningitis, encephalitis, or subarachnoid hemorrhage is suspected). Epileptic seizures have many causes, and some epileptic syndromes have specific histopathologic abnormalities. A thyroid panel would indicate the health of the thyroid gland, which is not a factor in seizure activity.
A client has abnormal electrical activity that is contained to a limited area of the brain. Which type of seizure is the client experiencing? A. Febrile B. Tonic-clonic C. Generalized D. Focal
Answer: D Rationale: Focal seizures (also known as partial seizures) occur when abnormal electrical activity is contained to a limited area of the brain. Generalized seizures affect both hemispheres in the brain. Tonic-clonic and febrile seizures are types of generalized seizures, not focal seizures.
The nurse is administering an oral antiseizure medication to an adult client. Which intervention should the nurse implement when administering this medication? (Select all that apply.) A. Monitoring the client for seizure activity B. Monitoring oxygen levels C. Assessing the client for slurred speech D. Administering antiseizure medication 2 hours after antacids are administered E. Asking the client for a list of home medications
Answer: A, C, E Rationale: Antiseizure medications can cause slurred speech. The nurse would document this finding in the client's medical record. Antiseizure medications decrease the number of seizures or help control seizure activity. Antiseizure medications do not cure seizure disorder. The client may still have seizures. The nurse must monitor the client for seizure activity. Antiseizure medications interact with other medications such as antacids. The nurse would review the client's home medication list for possible issues with drug interactions. The nurse would monitor blood pressure, pulse, and respirations while the client is taking antiseizure medications in the healthcare facility. There is no indication to monitor the client's oxygen levels.
A client has been taking anticonvulsant medication for a seizure disorder. Which diagnostic test should the nurse expect the healthcare provider to prescribe? A. Triglycerides B. Serum calcium C. Lipid panel D. Serum glucose
Answer: B Rationale: Antiseizure medications, such as phenytoin (Dilantin), can contribute to the demineralization of bone, and the serum calcium should be monitored. While the results of monitoring blood lipids, triglycerides, and serum glucose are important as health indicators, they are not directly associated with seizure disorders.
The nurse is preparing a teaching session for a community support group for clients who have been recently diagnosed with a seizure disorder. The nurse should include which factor as the cause of most seizures? A. Hyperactivity of muscles B. Abnormal excessive electrical discharge from the cells of the brain C. High blood sugar D. Excess electrical stimulation of the heart
Answer: B Rationale: Seizures are believed to be the result of abnormal excessive concurrent electrical discharges from the cortical neuronal network of cells on the surface of the brain. Elevated blood glucose is a factor in the treatment of diabetes. Although the heart and muscles have measurable electrical impulses, they are not related to electrical impulses in the brain.
A client is experiencing a seizure and requires immediate intervention to preserve life. Which type of seizure is the client experiencing? A. Partial seizure B. Status epilepticus C. Complex partial seizure D. Petit mal seizure
Answer: B Rationale: Status epilepticus is a continuous seizure that lasts for more than 30 minutes or a series of seizures during which consciousness is not regained. Status epilepticus requires immediate intervention to preserve life. All seizures are an important indicator of a physiologic problem, but partial seizures, petit mal seizures, and complex partial seizures are not immediately life threatening.
A client is having a seizure. Which nursing intervention is of immediate importance? A. Administering medication B. Maintaining the airway C. Placing a padded tongue blade in the client's mouth D. Intubating the client
Answer: B Rationale: The immediate nursing interventions for a client during a seizure include ensuring the client's safety and maintaining the client's airway. It is not common for a client to be intubated during a seizure. Medication may be administered following the seizure. Never place anything in a client's mouth during a seizure; loose teeth may be knocked out and swallowed.
A client reports that they usually have a seizure on the first day of their period. Which response by the nurse is correct? A. "Having your period has no relationship to your seizures." B. "Menstruation is a common trigger for seizures." C. "What makes you think having your period is related?" D. "Females who have a lot of menstrual cramps often have seizure activity."
Answer: B Rationale: There are many triggers reported by clients that elicit seizure activity. Commonly reported triggers include menstruation, flashing lights (such as strobe lights), and odors (such as a specific perfume).
The nurse is conducting a home visit for a 6-year-old client who has myoclonic and absence seizures. The parents are following a ketogenic diet for the child. Which observation requires follow-up by the nurse? A. Parents administer medium-chain-triglyceride (MCT) oil as needed. B. Parents include low carbohydrate foods. C. Parents include low-fat foods for each meal. D. Parents monitor urine ketone levels regularly.
Answer: C Rationale: A ketogenic diet is occasionally used for children under age 8 who experience myoclonic and absence seizures. The diet is customized to the child to maintain ideal body weight, maximize ketosis, and achieve optimal seizure control. The diet involves high intake of fat (up to 80% of calories), adequate intake of protein (1 g/kg), and low intake of carbohydrates. The child's urine ketone values should be monitored weekly or more frequently. The most common complications are constipation, hyperlipidemia, and kidney stones. Constipation can be treated with MCT oil and increased fluids. Kidney stones are treated by increasing fluid intake and alkalinizing the urine. When the child on a ketogenic diet is hospitalized, it is important to limit glucose and dextrose from all sources, and normal saline IV fluid should be used. If the condition worsens, the child should always be referred to an epilepsy center, rather than home care.
A client's husband asks, "What should I do if my wife has a seizure to keep her safe?" Which response by the nurse is correct? A. "Monitor your wife's blood pressure." B. "Restrain your wife." C. "Place your wife in the side-lying position." D. "Insert a padded tongue blade in your wife's mouth."
Answer: C Rationale: During a seizure, placing the client in a side-lying position will help keep the client safe and promote oxygenation. Restraining the client, monitoring blood pressure, and inserting a tongue blade in the client's mouth will not keep the client safe during a seizure.
Which complementary health approach may be specifically tailored to assist in the identification of the warning signs of seizures? A. Behavior modification B. Massage C. Biofeedback D. Meditation
Answer: C Rationale: Neurofeedback (biofeedback) techniques may be specifically tailored to help individuals with epilepsy identify the warning signs of seizures to prevent a seizure from developing. Relaxation (such as massage and meditation) and behavior modification therapy are psychologic therapies that may help certain clients feel less anxious and better adjust to having epilepsy.
A client's mother asks the nurse if there is anything non-pharmacologic that her daughter can do to help with intractable seizures. Which response by the nurse is correct? A. "Taking megadoses of vitamins might be worth a try." B. "Eating a vegetarian diet has been proven to be successful." C. "Taking in extra sugar on a regular basis could be helpful." D. "Eating a ketogenic diet can be helpful."
Answer: D Rationale: The ketogenic diet (KD) is a high-fat, low-carbohydrate, controlled-protein diet that has been used since the 1920s for the treatment of epilepsy. The diet is a medical treatment and is usually only considered when at least two suitable medications have been tried and have not worked. Megadoses of vitamins and a vegetarian diet have not been studied or recommended in the treatment of epilepsy. When a child is on a ketogenic diet, it is important to limit glucose from all sources.
Which assessment data should the nurse obtain when completing a health history on a client with a seizure disorder? A. Vital signs B. Level of consciousness C. Neurologic exam D. Presence of auras
Answer: D Rationale: When completing a health history on a client with a seizure disorder, the nurse should obtain information about the client's aura. Vital signs, level of consciousness, and a neurologic exam are parts of the physical examination.
