Seizure/Sensory Perception ATI Q&A ***

1. A nurse is caring for a child who has absence seizures. Which of the following findings can the nurse expect? (Select all that apply.) A. Loss of consciousness B. Appearance of daydreaming C. Dropping held objects D. Falling to the floor E. Having a piercing cry

1. A. CORRECT: Loss of consciousness for 5 to 10 seconds is a clinical manifestation of an absence seizure. B. CORRECT: Behavior that resembles daydreaming is a clinical manifestation of an absence seizure. C. CORRECT: A child who is having absence seizures may drop a held object. D. INCORRECT: Falling to the floor is a clinical manifestation of a tonic-clonic seizure. E. INCORRECT: The presence of a piercing cry is a clinical manifestation of a tonic-clonic seizure. NcleX® connection: Physiological adaptations, alterations in Body systems

1. A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? (Select all that apply.) A. Provide privacy. B. Ease the client to the floor if standing. C. Move furniture away from the client. D. Loosen the client's clothing. E. Protect the client's head with padding. F. Restrain the client.

1. A. CORRECT: The nurse should implement privacy to minimize the client's embarrassment. B. CORRECT: The nurse should ease the client to the floor to prevent falling. C. CORRECT: The nurse should move the furniture away from the client to prevent injury. D. CORRECT: The nurse should loosen the client's clothing to minimize restriction of movement. E. CORRECT: The nurse should protect the client's head from injury by placing the client's head in her lap or using a pillow or blanket under the head during a seizure. F. INCORRECT: The nurse should not restrain the client, which may cause an injury or more seizure activity. NCLEX® Connection: Physiological Adaptations, Alterations in Body Systems

1. A nurse is caring for a an older adult client who has diabetes mellitus. The client reports loss of peripheral vision. For which of the following is the client at risk? A. Cataracts B. Open-angle glaucoma C. Macular degeneration D. Angle-closure glaucoma

1. A. INCORRECT: A client who has cataracts experiences a decrease in vision and sensitivity to lights. B. CORRECT: The nurse should anticipate that the client is experiencing open-angle glaucoma. Loss of peripheral vision is a clinical manifestation associated with this diagnosis. C. INCORRECT: A client who has macular degeneration experiences a loss of central vision. D. INCORRECT: A client who has angle-closure glaucoma experiences nausea and severe pain. NCLEX® Connection: Health Promotion and Maintenance, Health Screening

2. A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? A. Keep the client in a side-lying position. B. Monitor the client's vital signs. C. Reorient the client to the environment. D. Check the client for injuries.

2. A. CORRECT: The greatest risk to the client is aspiration during the postictal phase. Therefore, the priority intervention is to keep the client in a side-lying position so secretions can drain from the mouth. B. INCORRECT: Monitoring vital signs to determine the stability of the client is important, but it is not the priority nursing action. C. INCORRECT: Reorienting the client to the environment because the client may feel confused after a seizure is important, but it is not the priority nursing action. D. INCORRECT: Checking the client for injuries that may of occurred from involuntary movement during the seizure is important, but it is not the priority nursing action. NCLEX® Connection: Physiological Adaptations, Alterations in Body Systems

2. A nurse is caring for a child who just experienced a generalized seizure. Which of the following is the priority action for the nurse to take? A. Maintain in a side-lying position. B. Monitor vital signs. C. Reorient the child to the environment. D. Assess for injuries.

2. A. CORRECT: Using the airway, breathing, circulation priority-setting framework, the first action is to place the child in a side-lying position to maintain a patent airway and prevent aspiration of secretions. B. INCORRECT: Monitoring the child's vital signs is an appropriate action. However, it is not the priority action. C. INCORRECT: Reorienting the child to the environment following a generalized seizure is an appropriate action. However, it is not the priority action. D. INCORRECT: Assessing for injuries is an appropriate action. However, it is not the priority action. NcleX® connection: Physiological adaptations, alterations in Body systems

2. A nurse is caring for a client following a trabeculectomy. Which of the following statements should the nurse include in the teaching? A. "You may resume playing golf." B. "You need to tilt your head back when washing your hair." C. "You may continue driving to and from work." D. "You need to limit your housekeeping activities."

2. A. INCORRECT: The nurse should not instruct the client to resume playing golf. This could cause the client's intraocular pressure (IOP) to rise or possible injury to the eye. B. INCORRECT: The nurse should not instruct the client to tilt his head back when washing his hair. This could cause the client's intraocular pressure (IOP) to rise or possible injury to the eye. C. INCORRECT: Driving should be avoided until the client's vision is evaluated following surgery and the provider instructs the client about resuming driving. D. CORRECT: The nurse should instruct the client to limit housekeeping activities following cataract surgery. This activity could elevate the client's intraocular pressure (IOP) or result in injury to the eye. NCLEX® Connection: Physiological Adaptations, illness Management

3. A nurse is providing teaching to the parent of a child who is to have an electroencephalogram (EEG). Which of the following should be included in the teaching? A. "Decaffeinated beverages should offered on the morning of the procedure." B. "Do not wash your child's hair the night before the procedure." C. "Withhold all foods the morning of the procedure." D. "Give your child an analgesic the night before the procedure."

3. A. CORRECT: Caffeine can alter the results of an EEG and should be avoided prior to the test. B. INCORRECT: The child's hair should be washed to remove oils that permit adherence of the EEG electrodes. C. INCORRECT: Foods are not withheld prior to an EEG. D. INCORRECT: Analgesics may alter the results of an EEG and should be avoided prior to the test. NcleX® connection: reduction of risk Potential, diagnostic tests

3. A nurse is caring for a male older adult client who has a new diagnosis of glaucoma. Which of the following should the nurse recognize as risk factors associated with this disease? (Select all that apply.) A. Gender B. Genetic predisposition C. Hypertension D. Age E. Diabetes mellitus

3. A. INCORRECT: Gender is not a risk factor associated with glaucoma. B. CORRECT: Genetic predisposition is a risk factor associated with glaucoma. C. CORRECT: Hypertension is a risk factor associated with glaucoma. D. CORRECT: Age is a risk factor associated with glaucoma. E. CORRECT: Diabetes mellitus is a risk factor associated with glaucoma. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

3. A nurse is providing discharge instructions to a female client who has a prescription for phenytoin (Dilantin). Which of the following information should the nurse include? A. Consider taking oral contraceptives when on this medication. B. Watch for receding gums when taking the medication. C. Take the medication at the same time every day. D. Provide a urine sample to determine therapeutic levels of the medication.

3. A. INCORRECT: The nurse should not instruct the client to take oral contraceptives, because contraceptive effectiveness is decreased when taking phenytoin. B. INCORRECT: The nurse should instruct the client that phenytoin causes overgrowth of the gums. C. CORRECT: The nurse should instruct the client to take phenytoin at the same time every day to enhance effectiveness. D. INCORRECT: The nurse should instruct the client to have period blood tests to determine the therapeutic level of phenytoin. NCLEX® Connection: Pharmacological and Parenteral Therapies, Medication Administration

4. A nurse is teaching a group of parents about the risk factors for seizures. Which of the following should be included in the teaching? (Select all that apply.) A. Febrile episodes B. Hypoglycemia C. Sodium imbalances D. Low serum lead levels E. Presence of diphtheria

4. A. CORRECT: Febrile episodes can cause general tonic-clonic seizures in infants and young children. B. CORRECT: Seizure activity is a late manifestation of hypoglycemia. C. CORRECT: Seizure activity is a manifestation of hyponatremia and hypernatremia. D. INCORRECT: High serum lead levels is a risk factor for seizure activity. E. INCORRECT: Diphtheria is a respiratory illness causing difficulty breathing and is not a risk factor for seizures. NcleX® connection: Physiological adaptations, alterations in Body systems

4. A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (Select all that apply.) A. Overwhelming fatigue should be avoided. B. Caffeinated products should be removed from the diet. C. Looking at flashing lights should be limited. D. Aerobic exercise may be performed. E. Episodes of hypoventilation should be limited. F. Use of aerosol hairspray is recommended.

4. A. CORRECT: The nurse should instruct the client to avoid overwhelming fatigue, which may trigger a seizure by stimulating abnormal electrical neuron activity. B. CORRECT: The nurse should instruct the client to remove caffeinated products from the diet, which may trigger a seizure by stimulating abnormal electrical neuron activity. C. CORRECT: The nurse should instruct the client to refrain from looking at flashing lights, which may trigger a seizure by stimulating abnormal electrical neuron activity. D. INCORRECT: The nurse should instruct the client to decrease physical activity, which may help to avoid triggering a seizure. E. INCORRECT: The nurse should instruct the client to limit excess hyperventilation, which may trigger a seizure by stimulating abnormal electrical neuron activity. F. INCORRECT: The nurse should instruct the client to avoid using aerosol hairspray, which may trigger a seizure by stimulating abnormal electrical neuron activity. NCLEX® Connection: Physiological Adaptations, Alterations in Body Systems

4. A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following clinical manifestations should the nurse expect to find? (Select all that apply.) A. Eye pain B. Floating spots C. Blurred vision D. White pupils E. Bilateral red reflexes

4. A. INCORRECT: Eye pain is not a clinical manifestation associated with cataracts. B. INCORRECT: Floating spots are a clinical manifestation associated with retinal detachment. C. CORRECT: Blurred vision is a clinical manifestation associated with cataracts. D. CORRECT: White pupils are a clinical manifestation associated with cataracts. E. INCORRECT: Bliateral red reflexes are absent in a client who has cataracts. NCLEX® Connection: Basic Care and Comfort, Personal Hygiene

5. A nurse is assessing a client following cataract surgery. The client reports nausea and severe eye pain. Which of the following actions should the nurse take? A. Notify the provider. B. Administer an analgesic. C. Administer an antiemetic. D. Turn the client onto the operative side.

5. A. CORRECT: Following cataract surgery, the provider should be notified if the client is experiencing nausea and severe pain. B. INCORRECT: Analgesic medication should not be administered until the client is evaluated by the provider. C. INCORRECT: Antiemetic medication should not be administered until the client is evaluated by the provider. D. INCORRECT: Turning the client on her operative side could result in increased eye pain and worsen the nausea. NCLEX® Connection: Basic Care and Comfort, Rest and Sleep

5. A nurse is reviewing treatment options with the parent of a child who has worsening seizures. Which of the following should be included in the discussion? (Select all that apply.) A. Vagal nerve stimulator B. Additional antiepileptic medications C. Corpus callosotomy D. Focal resection E. Radiation therapy

5. A. CORRECT: The implantation of a vagal nerve stimulator is an option to provide seizure control. B. CORRECT: Additional antiepileptic medication can be added to the current medication regime to control seizures. C. CORRECT: A corpus callosotomy can be performed for uncontrolled seizures. D. CORRECT: A focal resection can be performed for uncontrolled seizures. E. INCORRECT: Radiation therapy is used in cancer treatment and is not used to control seizures. NcleX® connection: reduction of risk Potential, therapeutic Procedures

5. A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following information should the nurse include in the teaching? A. The use of a microwave to heat food is permitted. B. Inform a provider to order only a MRI when a scan is needed. C. Place a magnet over the implantable device when an aura occurs. D. The use of ultrasound diathermy for pain management is recommended.

5. A. INCORRECT: The client should be instructed to avoid using a microwave, which may affect the stimulator. B. INCORRECT: The client should be instructed to inform his providers about the stimulator, which would be affected if an MRI were performed. C. CORRECT: The client should be instructed to hold a magnet over the implantable device when an aura occurs so as to decrease seizure activity. D. INCORRECT: The client should be instructed to avoid the use of ultrasound diathermy for pain management because of its effect on the stimulator. NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures

6. A nurse is planning care for a client who is experiencing status epilepticus. Which concepts should the nurse include in the plan of care? Include the following: A. Related Content: Define the condition. B. Underlying Principles: Describe four possible causes. C. Nursing Interventions: Describe five actions during a seizure.

6. A. Status epilepticus is prolonged seizure activity occurring over a 30-min period. B. ● Withdrawal from alcohol ● Withdrawal from antiepileptic medication ● Infection ● Fever C. Nursing Interventions ● Maintain a patent airway. ● Perfom ECG monitoring. ● Review ABG results. ● Establish IV access. ● Administer lorazepam (Ativan). NCLEX® Connection: Physiological Adaptations, Alterations in Body Systems

6. A nurse is reviewing the discharge instructions for a client who has a new diagnosis of primary open-angle glaucoma and a new prescription for timolol (Timpotic) 0.25%. List at least three adverse effects that should be included in the teaching.

6. ● Adverse Effects ◯ CNS: lethargy, fatigue, weakness, anxiety, headache, somnolence, confusion, depression, psychotic dissociation ◯ CV: bradycardia, palpitations, syncope, hypotension, AV conduction disturbances, aggravation of peripheral vascular insufficiency, CHF ◯ Special senses: superficial punctate keratopathy, eye irritation including conjunctivitis, keratitis, blepharitis ◯ Skin: urticaria, rash, GI nausea, anorexia, dyspepsia ◯ Respiratory: difficulty breathing, bronchospasm ◯ Metabolic: hypokalemia, hypoglycemia ◯ Body as whole: fever NCLEX® Connection: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/ Side Effects/interactions

6. A nurse is planning care for a child who has tonic-clonic seizures. What nursing actions should be included in the plan of care? Describe nursing actions after a seizure.

• Maintain the child in a side-lying position to prevent aspiration and to facilitate drainage of oral secretions. • Check vital signs. • Assess for injuries, including the mouth. • Perform neurologic checks. • Allow the child to rest if necessary. • Reorient and calm the child (she may be agitated or confused). • Maintain seizure precautions, including placing the bed in the lowest position and padding the side rails to prevent future injury. • Note the time of the postictal period. Remain with the child. • Do not offer food or liquids until completely awake and has a swallow reflex. • Encourage the child to describe the period before, during, and after the seizure activity. • Determine if the child experienced an aura, which may indicate the origin of seizure in the brain. • Try to determine the possible trigger, such as fatigue or stress. • Document the onset and duration of seizure and client findings/observations prior to, during, and following the seizure (level of consciousness, apnea, cyanosis, motor activity, incontinence). NcleX® connection: Physiological adaptations, alterations in Body systems

6. A nurse is planning care for a child who has tonic-clonic seizures. What nursing actions should be included in the plan of care? Describe nursing actions during a seizure.

• Protect the child from injury. (Move furniture away, hold head in lap if on the floor.) • Position the child to maintain a patent airway. • Be prepared to suction oral secretions. • Turn the child to the side (decreases risk of aspiration). • Loosen restrictive clothing. • Do not attempt to restrain the child. • Do not attempt to open the jaw or insert an airway during seizure activity. (This may damage teeth, lips, or tongue.) Do not use padded tongue blades. • Remove glasses. • Administer oxygen. • Remain with the child. • Note the onset, time, and characteristics of the seizure. • Allow the seizure to end spontaneously.