Unit 4 - ICR - Seizures - NCO
The nurse notes that a 3-year-old child in a crib has a clamped jaw and is having a tonic-clonic seizure. What is the priority nursing responsibility at this time? 1 Applying restraints 2 Administering oxygen 3 Protecting the child from self-injury 4 Inserting a plastic airway in the child's mouth
3 Protecting the child from self-injury Because the child is in a crib, the nurse should remain, observe, and protect the child from injury to the head or extremities during seizure activity. An individual should never be restrained during a seizure; fractured bones or torn muscles and ligaments may result. Administering oxygen is useless until the seizure is over; the child is apneic during the seizure. Attempts at inserting an airway are futile and may damage the child's teeth and jaws.
A client develops a seizure disorder as a result of a traumatic fall. When the client returns to the clinic for a routine visit, the client states, "I have not had a seizure in 2 years. When can I stop taking my antiseizure medications?" What is the nurse's best response? 1 "A gradual reduction in seizure medication may be considered." 2 "You will require medication for the rest of your life." 3 "Enough time has passed since the last seizure. The medication probably will be discontinued at this visit." 4 "A minimum of 10 years without seizures is necessary before discontinuation of medications is considered."
1 "A gradual reduction in seizure medication may be considered." Specific protocols are designed to gradually reduce the dosage of antiseizure medications after a client is seizure free, provided the electroencephalogram is within acceptable limits. The client is monitored for seizure activity because recurrence is greatest within the first year after drug withdrawal. Depending on the status of the client, antiseizure medications may not be necessary for life. Medications must be withdrawn slowly to prevent an abrupt reduction in serum drug levels, which may precipitate a seizure. The response "A minimum of 10 years without seizures is necessary before discontinuation of medications is considered" indicates too long a time.
The nurse is assessing the client with subdural hematoma after a fall. The client was admitted for observation with a normal neurologic assessment on admission. Upon entering the room the nurse finds the client exhibiting seizure activity. Which is the first action the nurse should take? 1 Assess the client's airway. 2 Place pads on the side rails. 3 Notify the healthcare provider. 4 Leave and obtain the crash cart.
1 Assess the client's airway. Ensuring an airway is the first action in an emergency response to any client. Placing pads on the side rails during the procedure is too late; protecting the airway and client are priority. The healthcare provider will be notified as soon as the nurse ensures the client's safety and has a patent airway. The nurse should not leave the client during a seizure.
While in the playroom a school-aged child exhibits twitching of the right arm and leg that almost immediately progresses to a generalized tonic-clonic seizure with clenched jaws. What is the best action for the nurse to take after moving the child to the floor? 1 Moving objects away from the child 2 Taking the other children to their rooms 3 Inserting a plastic airway into the child's mouth 4 Positioning a large pillow under the child's head
1 Moving objects away from the child Safety is the priority during the seizure and objects should be moved away from the child. It is unsafe to leave the child during the seizure to take other children to their rooms. Attempting to open clenched jaws may result in injury to the child's teeth and jaw. Positioning a large pillow under the child's head may cause airway occlusion by forcing the neck onto the chin; a small, flat blanket will be more effective.
A nurse is caring for a school-aged child who has had a tonic-clonic seizure. How should the nurse describe the clonic phase? 1 Generalized rigidity 2 Loss of consciousness 3 Spasmodic body jerking 4 Tremors of upper extremities
3 Spasmodic body jerking The clonic phase of a tonic-clonic seizure is associated with the rapid rhythmic extension and relaxation of muscle groups throughout the body. Rigidity occurs during the tonic phase of a seizure. Loss of consciousness is not specific to the clonic phase; it occurs at the beginning of the tonic phase and continues into the clonic phase. The movements during the clonic episode are more marked than the movements of a tremor and occur throughout the body, not just in the extremities.
When making rounds, a nurse observes a client who is experiencing a seizure. What should the nurse do? 1 Hyperextend the client's neck 2 Move obstacles away from the client 3 Restrain the client's body movements 4 Attempt to place an airway in the client's mouth
2 Move obstacles away from the client Moving obstacles away from the client helps the client avoid hitting objects and thus prevents trauma during the tonic-clonic phase of the seizure [1] [2]. Hyperextending the neck is contraindicated; it may injure the client. Restraining the client's body movements is contraindicated; it may injure the client. Attempting to place an airway in the client's mouth during the tonic-clonic phase of the seizure can cause injury.
A lactating woman takes fluoxetine to treat depression. Her newborn developed tremors, seizures, and fever. Which drug-induced physiologic alterations may be responsible for the central nervous system effects of the drug on the neonate? 1 Increase in fat content 2 Increase in protein binding 3 Immature blood-brain barrier 4 Delayed first stooling
3 Immature blood-brain barrier Many drugs are able to enter the neonate's brain due to the immature blood-brain barrier causing central nervous system effects. Neonates have a low fat content. Protein binding is decreased in neonates because the liver is immature and produces fewer proteins. First pass elimination is decreased in neonates due to the liver's immaturity.
A client is admitted to the hospital after having a tonic-clonic seizure and is diagnosed with a seizure disorder. Which is most important for the nurse to include in a teaching program? 1 Explain ways to prevent physical trauma from occurring during a seizure. 2 Teach that anticonvulsant medications should be taken on an empty stomach. 3 Teach the client that the symptoms and treatment of seizure disorders are similar, regardless of the cause. 4 Explain to the client that it is not necessary to tell others of the illness because medication will control seizures.
1 Explain ways to prevent physical trauma from occurring during a seizure. The client may become injured in many ways during a seizure, and trauma prevention is a priority. Anticonvulsants can cause gastrointestinal disturbances, especially early in therapy, and should be taken with food. Seizures and seizure disorders are not similar; they vary greatly. Others should understand the condition and be taught how to help in case of a seizure.
While walking in the hall, a hospitalized client has a tonic-clonic seizure. To protect the client during the seizure, what should the nurse do? 1 Hold the client's extremities firmly. 2 Protect the client's head from injury. 3 Insert an airway between the client's teeth. 4 Have several staff members move the client to a soft surface.
2 Protect the client's head from injury. Rhythmic contraction and relaxation associated with a tonic-clonic seizure can cause repeated banging of the head. Holding extremities firmly is contraindicated because it can cause broken bones. Inserting an airway between the client's teeth is contraindicated because damage to the teeth can occur if force is used to insert an airway. Moving during a seizure can result in physical injuries; the client should be moved after the seizure.
During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion. Which statement about this type of seizures is true? Select all that apply. 1 These seizures are associated with amnesia. 2 These seizures increase the risk of injuries due to fall. 3 These seizures are most resistant to drug therapy. 4 These seizures are preceded by perception of an offensive smell. 5 These seizures cause one sided movement of extremities in the client
2 These seizures increase the risk of injuries due to fall. 3 These seizures are most resistant to drug therapy. Atonic (akinetic) seizures are characterized by a sudden loss of muscle tone lasting for seconds followed by postictal confusion. These seizures cause the client to fall because of the decreased muscle tone, which may result in injury. This type of seizure tends to be most resistant to drug therapy. Amnesia is associated with complex partial seizures. In simple partial seizures, the client reports an aura and perception of unusual sensations, such as an offensive smell and sudden onset of pain. Simple partial seizures are also associated with one-sided movement of the extremities.
A client is admitted to the emergency department in the midst of persistent tonic-clonic seizures (status epilepticus). Diazepam is to be administered immediately. In addition to decreasing central neuronal activity, what other effect does the nurse anticipate? 1 Relaxing peripheral muscles 2 Slowing cardiac contractions 3 Dilating tracheobronchial structures 4 Providing amnesia of the convulsive episode
1 Relaxing peripheral muscles Diazepam is a tranquilizer and anticonvulsant used to relax skeletal muscles during continuous seizures. Diazepam does not slow cardiac contractions. Diazepam does not dilate the tracheobronchial structures. Diazepam does not provide amnesia of the convulsive episode.
A client who had a tonic-clonic seizure of unknown etiology is to begin taking phenytoin. What instructions will the nurse give to the client? 1 Take the medication on an empty stomach. 2 Brush the teeth and gums three times daily. 3 Stop taking the drug if abdominal pain occurs. 4 Note any change in pulse and respiratory rates.
2 Brush the teeth and gums three times daily. Adequate dental hygiene is essential to control or prevent the common side effect of hypertrophy of the gums. The medication should be taken with food or milk to decrease gastrointestinal side effects. The healthcare provider should be consulted before the drug is discontinued or the dosage is adjusted; usually in this situation, a gradual dosage reduction is prescribed. Changes in pulse and respiratory rates are unrelated to phenytoin therapy.
A client has a tonic-clonic seizure at work and is admitted to the emergency department. Which question is most useful when planning nursing care related to the client's seizure? 1 "Is your job demanding or stressful most of the time?" 2 "Do you participate in any strenuous sports activities on a regular basis?" 3 "Does anyone in your family have a history of central nervous system problems?" 4 "Were you aware of anything different or unusual just before your seizure began?"
4 "Were you aware of anything different or unusual just before your seizure began?" Identification of a sensation that occurs before each seizure [1] [2] (aura) is helpful in identifying the cause of the seizure and planning how to identify and avoid a future seizure. Although the response "Is your job demanding or stressful most of the time?" may provide some information, it is not the most inclusive question the nurse can ask; also, it limits the client's reply. Although the response "Do you participate in any strenuous sports activities on a regular basis?" may provide some information, it is not the most inclusive question the nurse can ask; also, it limits the client's reply. Although the response "Does anyone in your family have a history of central nervous system problems?" may provide some information, it is not the most inclusive question the nurse can ask; also, it limits the client's reply.
A client has a tonic-clonic seizure caused by an overdose of aspirin. What is an appropriate nursing action? 1 Check reflexes every 2 hours. 2 Prepare a setup for a central venous pressure (CVP) line. 3 Insert a urinary retention catheter. 4 Monitor vital signs every 15 minutes.
4 Monitor vital signs every 15 minutes. Because of the lethal toxicity of an aspirin overdose, hypotensive crisis and cardiac irregularities can occur. The central nervous system is not involved at the reflex level at this time. CVP readings are not indicated in this situation. Inserting a urinary retention catheter is not the priority at this time.
A school-aged child with a seizure disorder has been taking carbamazepine for three years. What nursing intervention is most important to undertake regularly? 1 Assessing the mouth for gingivitis 2 Checking the pupillary reaction to light 3 Keeping an accurate intake and output record 4 Monitoring the child's complete blood cell counts
4 Monitoring the child's complete blood cell counts The side effects of carbamazepine include blood dyscrasias (e.g., thrombocytopenia, aplastic anemia, leukopenia, agranulocytosis). A side effect of long-term phenytoin, not carbamazepine, therapy is hyperplasia of the gingiva. Carbamazepine does not influence pupillary response directly. Keeping an accurate intake and output is unnecessary.
A client has a tonic-clonic seizure. Which is the priority nursing intervention during the tonic-clonic stage of the seizure? 1 Go for additional help 2 Establish a patent airway 3 Turn the client on the side 4 Protect the client from injury
4 Protect the client from injury Protecting the client from injury, together with observation and documentation of the seizure activity, is the primary nursing care for a client with a tonic-clonic seizure. The client should not be left unattended. Establishing a patent airway is done after the seizure; the mouth should not be pried open to insert an airway during a seizure because injury may occur. Turning the client on the side will assist with establishing an airway after the seizure, but it is an unsafe action during a seizure.
A 7-year-old child who is taking medication to prevent seizures has been seizure free for 2 years. The child's parents ask a nurse, "How much longer will my child need to take the medication?" What is the best response by the nurse? 1 "Medications are continued for 3 years after the last seizure." 2 "It is important that the medications be gradually decreased." 3 "Medications are usually discontinued at the 2-year follow-up visit." 4 "Seizure disorders are lifelong problems that require ongoing medications."
2 "It is important that the medications be gradually decreased." A predesigned protocol is used to wean a child off anticonvulsants gradually because abrupt removal of the drug can result in a seizure. Anticonvulsants are discontinued gradually after a child is seizure free for 2, not 3, years and has an EEG within expected limits. Anticonvulsants cannot be stopped abruptly at the 2-year follow-up visit, but the discontinuation process may be started. The statement that seizure disorders are lifelong problems that require ongoing medications may or may not be true; this is determined on an individual basis.
A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched jaw. What is the best initial action by the nurse? 1 Trying to open the jaw 2 Placing the child on the floor 3 Calling out for assistance from staff 4 Placing a pillow under the child's head
2 Placing the child on the floor Placing the child on the floor limits the danger of falling and striking the head. Attempting to open the jaw is unsafe; it may result in injury. Protecting the child is the priority; assistance at this time is futile. Placing a pillow under the child's head may cause airway occlusion by forcing the chin onto the neck.
Which antiepileptic drug is used as the first-line treatment for absence seizures? 1 Phenytoin 2 Diazepam 3 Valproic acid 4 Acetazolamide
3 Valproic acid Valproic acid is used as the first-line treatment for absence seizures. Phenytoin is used to treat partial, secondary, and generalized tonic-clonic seizures. Diazepam is used to treat status epilepticus. Acetazolamide is used as an adjunct drug for the treatment of absence seizures.
A client who has a history of seizures is scheduled for an arteriogram at 10:00 AM and is to have nothing by mouth before the test. The client is scheduled to receive an anticonvulsant medication at 9:00 AM. What should the nurse do? 1 Omit the 9:00 AM dose of the drug. 2 Give the same dosage of the drug rectally. 3 Administer the drug with 30 mL of water at 9:00 AM. 4 Ask the healthcare provider if the drug can be given intravenously.
4 Ask the healthcare provider if the drug can be given intravenously. To achieve the anticonvulsant effect, therapeutic blood levels must be maintained. If the client is not able to take the prescribed oral preparation, the healthcare provider should be questioned about alternate routes of administration. Omission will result in lowered blood levels, possibly to less than the necessary therapeutic level to prevent a seizure. The route of administration cannot be altered without healthcare provider approval. The client is being kept nothing by mouth.
