HESI Case Study: Seizure Disorder
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.
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.
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.
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.
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.
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.
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.
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.
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.
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?"
- Are you currently taking any type of illegal drugs? Illegal drugs are not a typical cause for seizure activity. - "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.
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.
27. Which client teaching goal is most important to determine 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.
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.
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.
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.
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 the client if they want family in the room. - Pad and elevate the side rails of the client'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 the client's bed. The client is at high risk for injury because of the recent seizure activity. Protecting the client from injury by elevating and padding the side rails helps address safety needs.
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.
The client responds to the nurse's questions and then tells the nurse that someone has been talking to them about seizures and asked if they had aura with the seizure. The client asks the nurse to explain what is an aura.
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The client shares with the nurse that they are really worried about having a seizure the next time they menstruate.
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Once the client having the seizure is taken to the private room, the other people are brought back into the waiting room. The client who witnessed the seizure sits down and after 20 minutes is called back to the neurologist's office.
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Prior to discharge the nurse evaluates the client teaching provided during this hospitalization.
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The client appears overwhelmed with all the information the neurologist discussed with them. The client tells the nurse that they don't understand why the neurologist is ordering an MRI. Click for Image
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An hour later, the client is awake and alert. The client does not remember what happened but remembers hearing a buzzing sound. The next thing the client remembered is waking up in the emergency department.
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The client's family tells the nurse they have ever seen the client have a seizure. They have read all the information on epilepsy and have talked to the client and the neurologist about the seizures but are very worried about the client. The family tells the nurse that they don't think they would know what to do if they saw the client have a seizure.
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Another member of the group asks if there are any activities that should be avoided.
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While talking on the phone, the client asks the nurse about driving her car. The client states they have not been driving due to the medications, but hasn't had a seizure in 2 months and is not drowsy. The client asks if they can start driving her car.
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The client shares they are worried about being able to have children. The client doesn't have a significant other right now, but someday wants to get married and raise a family.
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The nurse continues to teach about the newly prescribed anticonvulsant medication. Click for Image
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The client's serum phenytoin level is 7 mcg/mL. The client has intravenous fluids of 5% Dextrose in Water (D5W) infusing at 100 mL/hour in the left forearm. The emergency department physician prescribes phenytoin 25 mg intravenous push.
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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.
Section 15
Discharge Home The client is discharged from the hospital after 2 days. The client's phenytoin level is 10.4 mcg/mL after receiving intravenous phenytoin. The neurologist changed the anticonvulsant from phenytoin to divalproex sodium to reduce possible side effects and increase compliance with medication administration.
26. 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 phenytoin, 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.
Therapeutic Communication
During the teaching session, the client shares with the nurse they are very scared because they really don't remember having the seizure. The client states never seeing someone with a seizure until the other day in the neurologist's office. The client says that illness has never been part of their life, and they don't feel sick now.
Health Promotion
Education is the key to treating epilepsy. The office nurse teaches the client about how to reduce the incidence of seizure activity and how to promote safety during a seizure.
25. Which statement reflects that the nurse is sensitive to Alanna's cultural needs? - Inform the family it will be better if they allowed the client to eat the food cooked by the hospital. - Exchange the food provided on the hospital tray with the food brought by family and deliver the tray to the client's room. - Return the tray provided by the hospital and ask the client if they would like to take the meal they provided to their room. - Offer to order additional guest trays from the hospital kitchen so that the client's parents can eat with them.
Return the tray provided by the hospital and ask the client if they would like to take the meal they provided to their room. This action supports the client's cultural food preferences, while also ensuring that the foods they brought in do not come in contact with the other foods and are not inadvertently served on dinnerware used for the hospital foods.Even though the client does not have diet restrictions, a ketogenic diet seems to prevent seizure activity.
Meet the Client
The client is a is referred to a neurologist by there family healthcare provider (HCP) because they had two probable seizures during the last 2 months. The client, a sales clerk in a department store, has been attending the local university part-time for the last 5 years, majoring in business. The client lives with a roommate in a small apartment about 20 miles from family. The client decides to come to the appointment with the neurologist alone and is sitting in the neurologist's waiting room.
Nursing Care
The client is admitted to the medical unit, and their family arrived a few minutes later. The client is drowsy but arouses easily to verbal stimuli.
Section 14
The client later tells the nurse they and their family follow a strict diet. The next morning, family arrives at the nurses' station with breakfast for the client that includes foods from their strict diet. The client has no prescribed dietary restrictions.
Section 12
The client tells the nurse the medication just made them feel funny and they really didn't think they would have any more seizures, so the client quit taking the medication 2 weeks ago. The client is admitted into the hospital for observation.
Section 3
The client tells the nurse they remembers hearing a buzzing sound, and then the next thing they knew someone was waking them up. The neurologist comes into the room and completes the client's history and physical along with the nurse. With the client's history, the neurologist thinks they had seizure activity and wants to determine exactly what is causing the new onset of seizure activity.
Support Group Meeting
The client, the clinet's roommate, and family 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, if it is it okay to swim at the local YMCA.
Section 10
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, the client privately asks the nurse, when is the best time to tell a potential significant other that they have a seizure disorder.
Medication Teaching
The neurologist informs the client no brain tumor, infection, or trauma was found, however there was seizure brain wave activity during the EEG. This brain activity is indicative of epilepsy. The neurologist prescribes phenytoin, an anticonvulsant, to help prevent the seizure activity. The clinic nurse teaches the client about the medication, its side effects, and the need to take it every day.
Diagnostic
The neurologist schedules an electroencephalogram (EEG) and a magnetic resonance image (MRI) to help evaluate the client's seizure disorder. The nurse discusses the tests with the client.
Case Outcome
The new anticonvulsant, divalproex sodium, does not make the client feel funny and they take it faithfully. The client continues to work as a sales clerk, plans to graduate from college next semester, and remains active in the the community. The client, the client's roommate, and family attend the monthly Epilepsy Support Group at the local hospital.
Assessment
The nurse asks the client why they have been referred. The client reports that 2 weeks ago their roommate found them passed out on the floor. The client states they could not remember what happened but thought it might be because they had not been eating right. Then, last week their roommate found them making unusual sounds and noticed that their arms and legs were jerking. At that time the client was taken to the emergency department. The client has the emergency department records and past history medical records from their family healthcare provider.
An Emergency Occurs
Three weeks later, the client is transported to the emergency department by an ambulance, accompanied by their roommate. The client's roommate states that the client was watching television and had a seizure. As soon as the first seizure stopped, a a second seizure started and the roommate called 911. The client is lying on the stretcher with eyes closed, but there is no seizure activity at this time.
Legal Issues
Two months after being diagnosed with the seizure disorder, the client calls the office and tells the nurse their job's supervisor is going to be let her go because of their seizure disorder. The client is very upset and tells the nurse they have been working at the same department store for several years.
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 the individual the truth on the first date so they will know. Veracity is truth-telling, and it is reflected by this response.
