Jackson Weber Pre Vsim

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?

Absence Rationale: Absence seizures consist of sudden cessation of activity combined with a blank facial expression. This type of seizure lasts less than 30 seconds and can occur multiple times during the day. Because of the subtle changes in patient behavior, absence seizure activity may not be recognized or may be perceived falsely as inattentiveness. Myoclonic seizures are characterized by sudden, brief, massive muscle jerks that may involve the whole body or one body part. Simple partial seizures are characterized by clonic or tonic movements involving the face, neck, and extremities and can include sensory signs such as numbness, tingling, paresthesia, or pain. Atonic seizures involve a sudden loss of muscle tone, which in children may be only a sudden drop of the head. pp. 490-491, Table 16.2

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, Head trauma, Incontinence Rationale: A child with altered level of consciousness may not be able to manage their secretions and is at risk for aspiration and ineffective airway clearance. Because of the loss of consciousness and rhythmic clonic contractions associated with this type of seizure, the patient is at risk for head trauma. Loss of sphincter control, leading to incontinence, is another complication associated with this type of seizure. Cardiac arrest and anaphylactic shock are not complications commonly associated with tonic-clonic seizures. p. 475 pp. 483-485 pp. 489-491, Table 16.2

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?

Further assessment is needed regarding phenobarbital administration and adherence to therapy. Rationale: During the health history, the nurse needs to determine what medication the patient is taking, the current prescribed dose of medication, the frequency of administration, and the duration of therapy as well as whether the patient is adhering to the prescribed medication regimen. There is not enough information provided in the description as it stands to conclude whether any of the other answers are correct. The nurse needs to know the last time the provider changed the child's medication dose, whether the child has had any recent weight changes, and when the provider last assessed the child's drug levels. p. 494

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, Keep oxygen and suction at the bedside Rationale: Basic seizure precautions should be implemented to provide a safe environment for the patient. The bed should be kept in low position and objects removed from the bed. Oxygen and suction should be readily available at the bedside. Supervision during bathing, ambulation, and other potentially unsafe activities helps to reduce the risk of an injury in the event that a seizure occurs. Although a ketogenic diet is a nonpharmacologic treatment for epilepsy, it would not be appropriate for the nurse to implement this without an order from the provider. There is no need to insert an indwelling catheter for a patient at risk for seizures. p. 485, Box 16.1

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 actions) should the nurse take? (Select all that apply.)

Check for a patent airway, Raise the side rails and remove any safety hazards. Rationale: The nurse should ensure that the child has a patent airway and adequate oxygenation. Implementation of seizure precautions, including raising the side rails and removing any safety hazards, helps to keep the environment safe and reduce the risk of injury. The patient should be placed in side-lying position, not supine, to help maintain a patent airway and decrease the risk for aspiration. Restraining the patient or placing anything in the mouth, such as a tongue blade, while the patient is actively seizing can cause further injury. The nurse should administer anticonvulsant medications as ordered to help stop and prevent further seizure activity, but administering oral medications during a seizure is not indicated due to risk of aspiration. p. 485, Box 16.1

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?

Collaborator Rationale: The pediatric nurse serves as a collaborator by working with the entire interdisciplinary health care team to integrate the needs of the patient and family into a coordinated plan of care. In the role of educator, the nurse instructs and counsels patients and their families about all aspects of health and illness. As an advocate, the nurse safeguards and advances the interests of patients and their families As a consultant, the nurse ensures that the needs of the patient and family are met through activities that include support group facilitation and working with the school nurse to plan the patient's care. p. 13