Seizure Disorders (Pearson questions)
The nurse observes a school-age child have an absence seizure. How would the nurse describe this seizure in the client's medical record? A) "Pulled arms in toward the body and flexed hands over the chest. This lasted 2 minutes." B) "Became unconscious, and all four extremities were jerking uncontrollably for 2 minutes." C) "Repeatedly moved from the chair to the bed while touching the arms for a length of 2 minutes." D) "Sat very still and was unresponsive with a blank stare for 2 minutes."
D (rationale: Absence (petit mal) seizures are characterized by sudden, brief cessation of all motor activity accompanied by a blank stare and unresponsiveness. These seizures are more common in children than in adults. Jerking of extremities and periods of nonpurposeful movements describe grand mal and generalized seizure activity. Decerebrate posturing is a sign of increased ICP.)
The nurse is planning discharge teaching for a child with epilepsy prescribed phenytoin (Dilantin). Which information is important for the nurse to include in these instructions? A) Brush teeth less frequently. B) Take the medication with milk. C) Increase fluid intake. D) Increase vitamin D intake.
D (rationale: Because phenytoin (Dilantin) can cause gingival hyperplasia, good dental hygiene should be encouraged. Fluid intake does not affect the drug's effectiveness, an adequate intake of vitamin D should be encouraged, and phenytoin (Dilantin) should not be taken with dairy products.)
The nurse is caring for a 1-year-old who starts to have a tonic-clonic (grand mal) seizure while in a crib in the hospital. The child's jaws are clamped shut. What is the most appropriate nursing action? A) Place a tongue blade between the child's jaws. B) Restrain the child to prevent injury. C) Prepare the suction equipment. D) Stay with the child to observe for complications.
D (rationale: During a seizure, the nurse remains with the child, watching for complications. Be sure nothing is placed in the child's mouth during a seizure. Suction equipment should already be set up at the bedside before a seizure begins. The child should not be restrained during a seizure.)
A 78-year-old client is experiencing a tonic-clonic (grand mal) seizure exceeding 10 minutes in length. Which medication should the nurse prepare to administer to this client? A) Intramuscular injection of diazepam B) 5% dextrose solution IV C) Intravenous diazepam slowly over several minutes D) Intravenous bolus of 10% dextrose
C (rationale: Grand mal, or tonic-clonic, seizure requires prompt management if it continues after 10 minutes has elapsed. Although IV fluids are indicated, a dextrose solution is not indicated. Diazepam may be administered by an IV slowly over several minutes, but not intramuscularly.)
The nurse makes a visit to the home of an adolescent recently discharged from the hospital for a seizure disorder. Which observations indicate that outcomes for care have been achieved? Select all that apply. A) The client is not driving. B) The client has not had a seizure for 1 month. C) The client is participating in the school basketball team. D) The client has bruises on both arms from seizure activity. E) The client has several episodes of constipation each week.
A, B, C (rationale: Depending on state laws, most clients with seizure disorders can drive after they have been seizure-free for at least 2 years. Cessation of seizure activity indicates that medication therapy has been effective. The client's self-esteem is enhanced through participation in well- supervised sports and activities, indicating that care has been effective. Physical bruising indicates that treatment for a seizure disorder has not been effective. Constipation is a complication of a ketogenic diet used to help control seizure activity and would indicate that care has not been effective.)
The nurse identifies the diagnosis Risk for Trauma as appropriate for a client with a seizure disorder. Which nursing interventions should be done if the client has a seizure? Select all that apply. A) Turn the client to a lateral position, if possible. B) Stay with the client. C) Insert a tongue blade into the client's mouth. D) Call for help. E) Restrain the client.
A, B, D (rationale: The nurse should stay with the client and call for assistance, if needed. If possible, the client should be turned onto the lateral position, not supine, to allow for any secretions to drain out of the mouth. Research has found that more injury can occur to the client if the caregiver tries to place something in the mouth during the seizure than if the caregiver does not. A client should never be restrained during a seizure.)
A 4-year-old client with myoclonic seizures has been on a ketogenic diet for the last 6 months to reduce seizure activity and is complaining of left-sided abdominal pain. Which complication of the ketogenic diet should the nurse suspect the client is experiencing? A) Bowel obstruction B) Renal calculi C) Urinary tract infection D) Appendicitis
B (rationale: Renal calculi are seen in 5% of children on a ketogenic diet. Appendicitis does not occur as a result of the ketogenic diet. Ketogenic diet does not cause a bowel obstruction. Urinary tract infections are not a result of a ketogenic diet.)
The nurse provides teaching about phenytoin (Dilantin) to the mother of a school-age child with a seizure disorder. Which statement made by the mother indicates that teaching has been effective? A) "I will give his medicine on an empty stomach so he will absorb it better." B) "I will check his gums and increase visits to the dentist." C) "I will use a carbonated beverage to dilute his medication." D) "I will let him chew his tablet."
B (rationale: There is no dietary recommendation for taking phenytoin (Dilantin). Gingival hyperplasia can occur in clients who take phenytoin (Dilantin). Carbonated beverages should not be used to dilute medication doses. Unless the medication is prescribed as chewable, the client should not be permitted to chew the dose.)