NCLEX | Seizure Practice Questions (Peds/Adult)

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take?Select all that apply. 1. Loosening restrictive clothing 2. Restraining the client's limbs 3. Removing the pillow and raising padded side rails 4. Positioning the client to the side, if possible, with the head flexed forward 5. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist

1, 3, 4 Rationale: Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on 1 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. Test- Taking Strategy: Focus on the subject, interventions during a seizure. Think about ethical and legal issues to eliminate option 5. Next, evaluate this question from the perspective of causing possible harm. No harm can come to the client from any of the options except for restraining the limbs. Remember to avoid restraints

The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply. 1. Time the seizure. 2. Restrain the child. 3. Stay with the child. 4. Place the child in a prone position. 5. Move furniture away from the child. 6. Insert a padded tongue blade in the child's mouth.

1, 3, 5 Rationale: A seizure is a disorder that occurs as a result of excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side prevents aspiration because saliva drains out the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure.

Risk factors for febrile seizures include: a. Family history of febrile seizures. b. Viral infections. c. Family history of epilepsy. d. a and b. e. a, b, and c.

d. a and b.

A 6-year-old child is seen in the urgent care unit for a history of seizures at home. He begins to have seizures in the urgent care unit that last more than 5 minutes. IV access has not been successful. The nurse caring for this child is knowledgeable that either of these medications may be given to stop the child's seizures: a. IM phenytoin b. Rectal diazepam c. Buccal midazolam d. a and c e. b and c

e. b and c (Rectal diazepam & Buccal midazolam)

1The type of seizure, also known as a petit mal seizure, that occurs more often in children between the ages of 4 and 12 years is the: a. generalized seizure. b. absence seizure. c. atonic seizure. d. jackknife seizure.

b. absence seizure.

The risk factors associated with recurrence of epilepsy include: a. polytherapy. b. abnormal electroencephalogram (EEG). c. frequent seizures on antiepileptic medication. d. a, b, and c.

d. a, b, and c.

Fosphenytoin may be given IV to treat childhood seizures instead of phenytoin because the former drug: a. is compatible with glucose and saline solutions. b. has fewer complications. c. may be given IM. d. may be administered at a faster rate. e. a, b, c, and d.

e. a, b, c, and d.

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should 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 3. Placing the bed in the high position 4. Putting a padded tongue blade at the head of the bed 5. Placing oxygen and suction equipment at the bedside 6. Flushing the intravenous catheter to ensure that the site is patent

1, 2, 5, 6 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 railsofthe bed are padded, and the bed iskept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking patency of the catheter. The use of padded tongue blades ishighlycontroversial, and theyshould 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. Ifthe client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins. Test- Taking Strategy: Focus on the subject, seizure precautions. Evaluate this question from the perspective of causing possible harm. No harm can come to the client from any of the options except for placing the bed in the high position and using a tongue blade.

438. The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? 1. Emergency cart 2. Tracheotomy set 3. Padded tongue blade 4. Suctioning equipment and oxygen

4 Rationale: A seizure results from the excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. A type of generalized seizure is a tonic-clonic seizure. This type of seizure causes rigidity of all body muscles, followed by intense jerking movements. Because increased oral secretions and apnea can occur during and after the seizure, oxygen and suctioning equipment are placed at the bedside. A tracheotomy is not perform ed during a seizure. No object, including a padded tongue blade, is placed into the child's mouth during a seizure. An emergency cart would not be left at the bedside, but would be available in the treatment room or nearby on the nursing unit.