HESI: Seizure Disorder and Rationale

21. 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. 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 the client took the last oral dose of her phenytoin.

Dilute the medication and flush the tubing before and after with normal saline. (Before infusion, dilute in 5% dextrose or 0.9% saline solution. Y-site compatibilities should be determined prior to administering the medication.)

27. Prior to discharge the nurse evaluates the client teaching provided during this hospitalization. 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.)

22. 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. Which question is most important for the nurse to ask the client? -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 phenytoin level is low, the nurse may infer that the client 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.)

2. After initial interventions are implemented, the client continues to have a tonic-clonic seizure. 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.)

5. 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. 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.)

4. Which of the medical history question(s) should the nurse ask to determine why the seizure activity started? (Select all that apply. One, some, or all options may be correct.) Are you currently taking any type of illegal drugs? Have you ever had any type of head injury? How many hours of sleep to you average a night? 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.)

1. The client is sitting in the waiting room when suddenly another client starts having a seizure. That client's entire body is rigid, arms and legs are contracting and relaxing, and they are making guttural sounds. This client yells for the nurse, who immediately comes into the waiting room. Prioritize the nursing actions in order from first action through last action. -Push the furniture away from the client. -Assess the client's blood pressure. -Safely move the client to the floor. -Remove people from the waiting room.

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. (Safety for the client is the most important action. The first priority is to lower the client to the floor so that they will have room to move their extremities. Second, move the furniture away so that the client will not injure themselves. Once the client is safely on the floor and away from obstacles, the third step is to provide privacy from on-lookers in the waiting room. Lastly, assessing the client's blood pressure must be done once the client's seizure activity has ended.)

15. 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. Which statement reflects 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.)

9. The nurse continues to teach about the newly prescribed anticonvulsant medication. 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 un-coordination. -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.)

26. 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. 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 hepatotoxic so liver function tests are monitored at follow-up visits.)

20. 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 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. Which intervention should the nurse implement first? -Assess the client's vital signs. -Obtain a serum phenytoin 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. Airway is priority.)

11. 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. The nurse's response is based on which scientific rationale? -Research shows 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. (The client will need preconception counseling when considering child birth. She will require special care and guidance before, during, and after pregnancy.)

8. 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. Which statement indicates understanding of 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 phenytoin. Thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care are essential to prevent this complication.)

14. Which statement indicates nursing education 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. (The client should carry a band or card at all times so her medical condition will be easy to identify.)

6. 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. Which action should the nurse include in preparing the client 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 the client 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.)

18. Another member of the group asks if there are any activities that should be avoided. 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.)

12. 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. Which health promotion activity should the nurse discuss with the client? -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.)

23. 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. 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.)

25. 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. What action should the nurse take? -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.)

17. The client, the client'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. 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. The client's family tells the nurse they have never 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. How should the nurse respond? -The most important thing is to keep the client from injuring themselves. -I know you would do the best that you could for your adult child. -It helps if you restrain the client's arms so that they won't flail about. -You should make sure the client takes their medication every day.

The most important thing is to keep the client from injuring themselves. (Protecting the client from injury is the most important action to take.)

7. 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. 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. 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. 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 the client's feelings and encourages her to continue to ventilate her feelings.)

3. After the client's seizure activity stops, they are 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. 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.)

16. 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. 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. 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. If the nurse believes in the ethical principle of veracity for the client, how should the nurse respond? -I 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 the individual the truth on the first date so they will know. -You are worried about how to tell your significant other 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.)

13. The client shares with the nurse that they are really worried about having a seizure the next time they menstruate. 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.)