ccrox96 Preview - murkacat Save Seizures - NCLEX 20 terms ccrox96...

Seizures NCLEX ScienceMedicineNursing murkacat Save Seizures - NCLEX 20 terms ccrox96Preview ICP Nclex Questions, ICP NCLEX sty...120 terms Mariko_Roberts Preview NCLEX Questions Parkinson Disease...20 terms SMathews926Preview Spinal 26 terms ET0 The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first?

• Push aside any furniture.
• Place the client on his side.
• Assess the client's vital signs.
• Ease the client to the floor.

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• The client should not remain in the

chair during a seizure. He should be brought safely to the floor so that he will have room to move the extremities.The occupational health nurse is concerned about preventing occupation-related acquired seizures. Which intervention should the nurse implement?

• Ensure that helmets are worn in appropriate areas.
• Implement daily exercise programs for the staff.
• Provide healthy foods in the cafeteria.
• Encourage employees to wear safety glasses.
• Head injury is one of the main reasons

for epilepsy that can be prevented through occupational safety precautions and highway safety programs.

The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which preprocedure teaching should the nurse implement?

• Tell the client to take any routine antiseizure medication prior to the EEG.
• Tell the client not to eat anything for eight (8) hours prior to the procedure.
• Instruct the client to stay awake for 24 hours prior to the EEG.
• Explain to the client that there will be some discomfort during the procedure.
• The goal is for the client to have a

seizure during the EEG. Sleep deprivation, hyperventilating, or flashing lights may induce a seizure.The nurse enters the room as the client is beginning to have a tonic-clonic seizure.What action should the nurse implement first?

• Note the first thing the client does in the seizure.
• Assess the size of the client's pupils.
• Determine if the client is incontinent of urine or stool.
• Provide the client with privacy during the seizure.
• Noticing the first thing the client does

during a seizure provides information and clues as to the location of the seizure in the brain. It is important to document whether the beginning of the seizure was observed.The client who just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement?

• Perform a complete neurological assessment.
• Awaken the client every 30 minutes.
• Turn the client to the side and allow the client to sleep.
• Interview the client to find out what caused the seizure.
• During the postictal (after-seizure)

phase, the client is very tired and should be allowed to rest quietly; placing the client on the side will help prevent aspiration and maintain a patent airway.

The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take?

• Help the UAP to insert the oral airway in the mouth.
• Tell the UAP to stop trying to insert anything in the mouth.
• Take no action because the UAP is handling the situation.
• Notify the charge nurse of the situation immediately.
• The nurse should tell the UAP to

stop trying to insert anything in the mouth of the client experiencing a seizure. Broken teeth and injury to the lips and tongue may result from trying to place anything in the clenched jaws of a client having a tonic-clonic seizure.The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication?

• "I will brush my teeth after every meal."
• "I will check my Dilantin level daily."
• "My urine will turn orange while on Dilantin."
• "I won't have any seizures while on this medication."
• Thorough oral hygiene after each

meal, gum massage, daily flossing, and regular dental care are essential to prevent or control gingival hyperplasia, which is a common occurrence in clients taking Dilantin.The client is admitted to the intensive care department (ICD) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate?

• Assess the client's neurological status every hour.
• Monitor the client's heart rhythm via telemetry.
• Administer an anticonvulsant medication by intravenous push.
• Prepare to administer a glucocorticosteroid orally.
• Administering an anticonvulsant

medication by intravenous push requires the nurse to have an order or confer with another member of the health-care team.

The client has been newly diagnosed with epilepsy. Which discharge instructions should be taught to the client? Select all that apply.

• Keep a record of seizure activity.
• Take tub baths only; do not take showers.
• Avoid over-the-counter medications.
• Have anticonvulsant medication serum levels checked regularly.
• Do not drive alone; have someone in the car.
• Keeping a seizure and medication chart

will be helpful when keeping follow-up appointments with the health-care provider and in identifying activities that may trigger a seizure.

• Over-the-counter medications may

contain ingredients that will interact with antiseizure medications or, in some cases, as with use of stimulants, possibly cause a seizure.

• Most of the anticonvulsant medications

have therapeutic serum levels that should be maintained, and regular checks of the serum levels help to ensure the correct level.Which statement by the female client indicates that the client understands factors that may precipitate seizure activity?

• "It is all right for me to drink coffee for breakfast."
• "My menstrual cycle will not affect my seizure disorder."
• "I am going to take a class in stress management."
• "I should wear dark glasses when I am out in the sun."
• Tension states, such as anxiety and

frustration, induce seizures in some clients, so stress management may be helpful in preventing seizures.The nurse asks the male client with epilepsy if he has auras with his seizures. The client says, "I don't know what you mean. What are auras?" Which statement by the nurse would be the best response?

• "Some people have a warning that the seizure is about to start."
• "Auras occur when you are physically and psychologically exhausted."
• "You're concerned that you do not have auras before your seizures?"
• "Auras usually cause you to be sleepy after you have a seizure."
• An aura is a visual, auditory, or

olfactory occurrence that takes place prior to a seizure and warns the client a seizure is about to occur. The aura often allows time for the client to lie down on the floor or find a safe place to have the seizure.