Jackson Weber Vsim

The nurse is teaching Jackson's parents about injury prevention when Jackson has a seizure at home. Which of the following statements) by the mother indicates that teaching has been effective? (Select all that apply.) - 'I will hold Jackson's head in my lap during the seizure to help prevent head injury.' - 'Rolling Jackson to his side will help him breathe better and keep him from choking.' - 'All toys and other hazards should be moved out of the way to keep Jackson safe.* - 'Someone should stay with Jackson until he fully wakes up after the seizure." - 'If Jackson stops breathing during the seizure, I need to push on his jaw to open his airway."

'Rolling Jackson to his side will help him breathe better and keep him from choking.' ; 'All toys and other hazards should be moved out of the way to keep Jackson safe.' ; 'Someone should stay with Jackson until he fully wakes up after the seizure."

The nurse is evaluating a school-aged patient brought in for a recent decline in academic performance. The parent reports that the patient has been doing poorly in school and states, 'He wastes time staring at the wall and daydreaming instead of completing his work. The nurse suspects that the patient may be experiencing which type of seizure activity? - Myoclonic - Absence - Simple partial - Atonic

Absence

The nurse recognizes that ____ is the most likely cause of Jackson's seizure, and it will be necessary to perform ____ before discharge.

medication nonadherence ; patient/family education

During an admission assessment, the nurse notes a sudden onset of tonic contractions of the patient's entire body followed by clonic contractions alternating with relaxation of all muscle groups. What action(s) should the nurse take? (Select all that apply.) - Check for a patent airway. - Place the patient in supine position. - Raise the side rails and remove any safety hazards. - Administer oral maintenance dose of anticonvulsant medications. - Use a tongue blade to keep the tongue from obstructing the airway.

Check for a patent airway. ; Raise the side rails and remove any safety hazards.

The role of the pediatric nurse has many components. Which of the following components includes the nurse's work with the interdisciplinary health care team to integrate the needs of the patient and family into a coordinated plan of care? - Educator - Collaborator - Advocate - Consultant

Collaborator

A nurse is reviewing lab results and notes that a 5-year-old patient's serum phenobarbital level is 8 mcg/mL. Phenobarbital is considered therapeutic at levels between 10 and 40 mcg/mL. What is the nurse's best interpretation of this data? - The patient has not been taking the phenobarbital as ordered by the provider. - The patient has developed a tolerance to phenobarbital, and another medication should be ordered. - The prescribed dose of phenobarbital is too low and needs to be increased to be therapeutic. - Further assessment is needed regarding phenobarbital administration and adherence to therapy.

Further assessment is needed regarding phenobarbital administration and adherence to therapy.

Jackson experiences a generalized tonic-clonic seizure while the nurse is caring for him. Which intervention(s) should the nurse perform initially to ensure Jackson's safety? (Select all that apply.) - Keep side rails raised at all times and padded. - Notify the physician immediately. - Place Jackson in side-lying position. - Ensure oxygen and suction are at bedside. - Provide reassurance to Jackson's caregiver. - Prepare to administer an antipileptic medication as prescribed.

Keep side rails raised at all times and padded. ; Place Jackson in side-lying position. ; Ensure oxygen and suction are at bedside.

Expected outcome(s) when caring for Jackson and his family include which of the following? (Select all that apply.) - He is free from seizures, or seizure activity is diminished. - Medications are administered and adhered to properly by Jackson's caregiver. - Jackson's caregiver and teachers demonstrate the correct actions to take to prevent injury when a seizure does occur. - Jackson experiences minimal side effects of seizure medications. - Jackson can discontinue anticonvulsant therapy. - Jackson's caregiver receives adequate support to cope with his condition.

He is free from seizures, or seizure activity is diminished. ; Medications are administered and adhered to properly by Jackson's caregiver. ; Jackson's caregiver and teachers demonstrate the correct actions to take to prevent injury when a seizure does occur. ; Jackson experiences minimal side effects of seizure medications. ; Jackson's caregiver receives adequate support to cope with his condition.

A nurse is explaining to Jackson's caregiver how to respond when Jackson has a seizure at home. Which of the following statements) by the caregiver indicate(s) that teaching has been effective? (Select all that apply.) - 'I will hold Jackson's head in my lap during the seizure to helo prevent head injury.* - 'Rolling Jackson to his side will help him breathe better and keep him from choking. - 'All toys and other hazards should be moved out of the way to keep Jackson safe.' - 'Someone should stay with Jackson until he fully wakes up after the seizure. - 'If Jackson stops breathing during the seizure, I need to push on his jaw to open his airway." - 'I should call EMS as soon as Jackson starts seizing."

'Rolling Jackson to his side will help him breathe better and keep him from choking. ; 'All toys and other hazards should be moved out of the way to keep Jackson safe.' ; 'Someone should stay with Jackson until he fully wakes up after the seizure.

The nurse is teaching Jackson's caregiver about phenobarbital and medication adherence. Which of the following statements) by Jackson's caregiver indicate(s) that teaching has been effective? (Select all that apply.). - 'Jackson will need to take the medication daily, even if he's not having seizures. - 'I will increase the dose of phenobarbital if Jackson starts to have an increased number of seizures.' - 'Jackson needs to take the phenobarbital at the same time daily.* - 'Jackson will need to have his phenobarbital levels checked regularly." - 'Since phenobarbital is expensive and Jackson isn't having seizures, I can give the medication every other day." - 'If there are no seizures noticed for 3 months, I can stop the medication.

'Jackson will need to take the medication daily, even if he's not having seizures. ; 'Jackson needs to take the phenobarbital at the same time daily.* ; 'Jackson will need to have his phenobarbital levels checked regularly."

A patient weighing 40 lb has an order for phenobarbital 60 mg twice daily. The safe dose range is 3 to 6 mg/kg/day. Is this order safe? - Yes, the safe range is 54.6 to 109.2 mg/day. - No, the safe range is 54.6 to 109.2 mg/day. - Yes, the safe range is 120 to 240 mg/day. - No, the safe range is 120 to 240 mg/day.

No, the safe range is 54.6 to 109.2 mg/day.

vSim

- You washed your hands. To maintain patient safety, it is important to wash your hands as soon as you enter the room. - You identified the child. To maintain patient safety, it is important that you quickly identify the child - You identified the relatives. This is important, as the patient is below 18 years of age. - You asked the parent: Does he have any known allergies? The parent replied: No. I don't think so - You attached the automatic noninvasive blood pressure (NIBP) measurement cuff. This will allow you to reassess the child continuously - You looked for normal breathing. He is breathing at 14 breaths per minute. The chest is moving equally. - You checked the temperature at the ear. The temperature was 98.1 F (36.7 C). - You assessed the pain level using the FACES scale. The child answered 0 on the FACES pain scale with a range of 0 to 10. - You assessed the child's neurological status: This is reasonable. - You listened to the lungs of the child. The breath sounds are clear and equal bilaterally. In the clinical situation, you should auscultate the lungs both anteriorly and posteriorly. - You listened to the heart of the child. There were regular heart sounds without murmurs. - You checked the radial pulse. The pulse is strong, 100 per minute, and regular. - A 60 mg dose of phenobarbital was given orally. The child should be sitting up when doing this. It is important to use the basic rights of medication administration to ensure proper drug therapy. This was indicated by order. - You put up seizure pads on the bed. This was indicated by order. - You secured the patient to avoid injuries during seizures - The child had a seizure. - The child's seizure stopped - You assisted the child into a recovery position. This can help avoid aspiration and airway obstruction in a postictal state. - You started suctioning. Suctioning is part ofthe correct treatment here. - You gave the child 100% oxygen (12 L) from a nonrebreathing mask. This was part of your orders. - You provided education to the relative regarding the child's condition. This is correct. It is important to use every opportunity to provide education. - You phoned the provider in order to discuss the patient. - You assessed the child's IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. This is correct. Assessing any IVs the child has is always important. - You looked for normal breathing. The chest is moving up and down.

SBAR

Situation Jackson is a 5-year-old boy admitted for neuro observation who just suffered a generalized tonic-clonic seizure for approximately 60 seconds with spontaneous recovery. Background Jackson was brought to the E D last night by his parent after experiencing four seizures at home within a 12-hour period. He was diagnosed with generalized tonic-clonic selzures 2 years ago. Upon diagnosis, the neurologist started him on oral phenobarbital. Jackson had been seizure-free until last night, when he was brought to the ED. He had one seizure in the ED, and it required the administration of lorazepam. He also received a loading dose of phenobarbital in the ED because his blood levels were low. All other blood work was normal. He has been prescribed phenobarbital twice a day. His parent is single and the sole source of financial support. His parent lost their job 3 months ago and so has not been able to afford his medications. His parent is at the bedside. Assessment Upon initial assessment, Jackson's vital signs were HR 86, RR 18, BP 104/62, temp 36.8°C (98.2°F), and SpO2 99% on room air. Initially. Jackson was alert and oriented to person, time, and place. A neurologie exam was performed before the episode of seizure activity: pupils were equal and reactive, extraocular eye movements were intact and normal, reflexes were intact, and neurologic exam was normal. He has an IV running 5% dextrose and 0.9% sodium chloride at 58 mL/hr, and dressing is dry and intact with no redness or swelling noted. Jackson had a generalized tonic-clonic seizure that lasted for approximately 60 seconds. The child was kept safe during the episode; all loose clothing was removed and seizure pads were in place. During the episode, SpO2 dropped to the 80s and oxygenivia a non-rebreather mask was started at 12 L/min. Following the episode, lungs were clear. Child responded with mumbles at first but, after 30 seconds, was able to reply to questions. Provider was notified and is on their way to come see the patient. Recommendation Continue to monitor patient for any changes in neurologic status or seizure activity. Educate family and patient on importance of medication adherence. Refer family to social services to address concerns about paying for medications.

The nurse must assess Jackson's neurologic status closely for signs of a tonic-clonic seizure, which may include ____ and lasts for ____

body shaking, stiffening, and jerking ; 1-3 minutes or longer

A nurse is caring for a preschool-aged patient experiencing generalized tonic-clonic seizures. This patient is at greatest risk for which of the following complication (s)? (Select all that apply.) - Aspiration - Cardiac arrest - Head trauma - Anaphylactic shock - Incontinence

Aspiration ; Head trauma ; Incontinence

The nurse is admitting a pediatric patient with a known seizure history with an order to implement seizure precautions. Which of the following intervention(s) should the nurse include in the patient's plan of care? (Select all that apply.) - Keep bed in low position and remove objects from the bed. - Supervise when ambulating or bathing. - Place the patient on a ketogenic diet. - Insert an indwelling catheter for incontinence. - Keep oxygen and suction at the bedside.

Keep bed in low position and remove objects from the bed. ; Supervise when ambulating or bathing. ; Keep oxygen and suction at the bedside.