N344: Exam 3: Seizures

41. The client who just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement?

A. Turn the client to the side and allow the client to sleep. R. During the postictal (after-seizure) phase, the client is very tired and should be allowed to rest quietly; placing the client on the side will help prevent aspiration and maintain a patent airway.

The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which of the following measures would the nurse include in planning for the client's safety? Select all that apply.

1. Padding the side rails of the bed 2. Placing an airway at the bedside 4. Placing oxygen and suction equipment at the bedside 6. Having intravenous equipment ready for insertion of an intravenous catheter Rationale: Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if anticonvulsant medications must be administered. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.

39. The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which preprocedure teaching should the nurse implement?

A. Instruct the client to stay awake for 24 hours prior to the EEG. R. The goal is for the client to have a seizure during the EEG. Sleep deprivation, hyperventilating, or flashing lights may induce a seizure.

46. Which statement by the female client indicates that the client understands factors that may precipitate seizure activity?

A. "I am going to take a class in stress management." R. Tension states, such as anxiety and frustration, induce seizures in some clients, so stress management may be helpful in preventing seizures

43. The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication?

A. "I will brush my teeth after every meal." R: Thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care are essential to prevent or control gingival hyperplasia, which is a common occurrence in clients taking Dilantin.

47. The nurse asks the male client with epilepsy if he has auras with his seizures. The client says, "I don't know what you mean. What are auras?" Which statement by the nurse would be the best response?

A. "Some people have a warning that the seizure is about to start." R: An aura is a visual, auditory, or olfactory occurrence that takes place prior to a seizure and warns the client a seizure is about to occur. The aura often allows time for the client to lie down on the floor or find a safe place to have the seizure.

44. The client is admitted to the intensive care department (ICD) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate?

A. Administer an anticonvulsant medication by intravenous push. R. Administering an anticonvulsant medication by intravenous push requires the nurse to have an order or confer with another member of the health-care team.

48. The nurse educator is presenting an in-service on seizures. Which disease process is the leading cause of seizures in the elderly?

A. Cerebral vascular accident (stroke) R: A CVA (stroke) is the leading cause of seizures in the elderly; increased intracranial pressure associated with the stroke can lead to seizures.

37. The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first?

A. Ease the client to the floor. R. The client should not remain in the chair during a seizure. He should be brought safely to the floor so that he will have room to move the extremities.

38. The occupational health nurse is concerned about preventing occupation-related acquired seizures. Which intervention should the nurse implement?

A. Ensure that helmets are worn in appropriate areas. R. Head injury is one of the main reasons for epilepsy that can be prevented through occupational safety precautions and highway safety programs.

45. The client has been newly diagnosed with epilepsy. Which discharge instructions should be taught to the client? Select all that apply.

A. Keep a record of seizure activity. R. Keeping a seizure and medication chart will be helpful when keeping follow-up appointments with the health-care provider and in identifying activities that may trigger a seizure. A. Avoid over-the-counter medications. R. Over-the-counter medications may contain ingredients that will interact with antiseizure medications or, in some cases, as with use of stimulants, possibly cause a seizure. A. Have anticonvulsant medication serum levels checked regularly. R: Most of the anticonvulsant medications have therapeutic serum levels that should be maintained, and regular checks of the serum levels help to ensure the correct level.

40. The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first?

A. Note the first thing the client does in the seizure. R: Noticing the first thing the client does during a seizure provides information and clues as to the location of the seizure in the brain. It is important to document whether the beginning of the seizure was observed.

42. The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take?

A. Tell the UAP to stop trying to insert anything in the mouth. R: The nurse should tell the UAP to stop trying to insert anything in the mouth of the client experiencing a seizure. Broken teeth and injury to the lips and tongue may result from trying to place anything in the clenched jaws of a client having a tonic-clonic seizure.

The nurse is caring for the client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated?

Restraining the client's limbs Rationale: Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client.