Scheduled maintenance: Saturday, September 10 from 11PM to 12AM PDT Show
Home Subjects Solutions Create Log in Sign up Upgrade to remove ads Only ₩37,125/year
Terms in this set (59)Client is having tonic-clonic seizure. Nurse should take which of the following actions? SELECT ALL THAT APPLY A.Restrain client BCE the nurse is caring for a client who begins to experience seizure activity while in bed. which action by the nurse is contraindicated? A. loosening restrictive clothing B the nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. which measures should the nurse include in planning care for the client's safety? Select all that apply A. padding the side rails of the bed ABEF a nurse is assessing a client who has seizure disorder. the client reports he thinks he is out to have a seizure. which of the following actions should the nurse implement (select all that apply) A. provide privacy ABCDE 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 A A nurse is providing discharge instructions to a female client who has a prescription for phenytoin. which of the following information should the nurse include? A.consider taking oral contraceptives when on this medication C a nurse is reviewing trigger factos that can cause seizures with a client who has na new diagnosis of generalized seizures. which of the following information should the nurse include in this review? (select all that apply) A. avoid overwhelming fatigue ABC a nurse is completing discharge teaching to a client who has seizures and received a vagal nerves stimulator to decrease seizure activity. which of the following statements should the nurse include in the teaching? A. it is safe to use microwave that are 1200 watts or less C A 6-year-old child is seen in the urgent care unit for a history of seizures at home. He begins to have seizures in the urgent care unit that last more than 5 minutes. IV access has not been successful. The nurse caring for this child is knowledgeable that either of these medications may be given to stop the child's seizures: a. IM phenytoin E The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? 1. Emergency cart 4 The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply. 1. Time the seizure. 135 The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take?Select all that apply. 1. Loosening restrictive clothing 134 The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1. Padding the side rails of the bed 1256 Which drug used in the treatment of seizures requires careful monitoring of renal function? A. Lamotrigine (Lamictal) C A patient taking phenytoin (Dilantin) and isoniazid reports feeling lethargic. Nystagmus is noted on physical examination. What problem does this information suggest to the nurse? A. Tubercular reactivation C Which antiepileptic drug is effective for almost all forms of seizures? A. Valproic acid (Depakene) A A patient with diabetes is started on phenytoin (Dilantin) for partial seizures. What does the nurse closely monitor in this individual? A. Blood pressure C A patient taking phenytoin (Dilantin) has started attending college and reports frequently drinking alcohol with friends. What does the nurse monitor for in this patient? A. Clinical manifestations of phenytoin toxicity D Which measurement is the best indicator of how well an antiseizure medication is working? A. Serum drug levels B In which patient is carbamazepine (Tegretol) contraindicated? A. Patient with new onset of seizures C A patient has been started on lamotrigine (Lamictal). How does the nurse instruct this patient to take the medication to decrease the incidence of gastric irritation? A. With milk or food A A client asks the nurse what might trigger a seizure. Which situation should the nurse include in the response? A.Exposure to
toxins A The nurse is teaching a client about possible seizure triggers. Which information should the nurse include? (Select all that apply.) A.Specific odors ABCE A client reports that they usually have a seizure on the first day of their period. Which response by the nurse is correct? A."Having your period has no relationship to your seizures." B The nurse is planning discharge teaching for a 30-year-old female client who was newly diagnosed with tonic-clonic seizures. Which information should the nurse include in this teaching plan? (Select all that apply.) A.Wearing a bracelet that provides health information ABDE The nurse is caring for a client with a seizure disorder currently controlled with antiseizure medication. The client states, "A friend recommended an herbal supplement for my depression. Can I take it?" Which response by the nurse is correct? A."St. John's wort has been known to decrease the effectiveness of your antiseizure medication." A A client's mother asks the nurse if there is anything non-pharmacologic that her daughter can do to help with intractable seizures. Which response by the nurse is correct? A."Taking megadoses of vitamins might be worth a
try." D Which complementary health approach may be specifically tailored to assist in the identification of the warning signs of seizures? A.Behavior modification C A 50-year-old client with a newly diagnosed seizure disorder is depressed because they are not allowed to drive and have lost their independence. Which question should the nurse ask to support the client? (Select all that apply.) A."What does being able to drive mean to you?" ABCE The nurse is administering an oral antiseizure medication to an adult client. Which intervention should the nurse implement when administering this medication? (Select all that apply.) A.Monitoring the client for seizure activity ACE Medication has been ineffective in controlling a client's seizures. Which treatment option should the nurse suspect will be discussed with the client? A.Surgical resection A The nurse is admitting a client with a history of frequent tonic-clonic seizures. Which information would be most valuable for the nurse to obtain when performing the health history assessment? (Select all that apply.) A.Presence of auras ACD Which assessment data should the nurse obtain when completing a health history on a client with a seizure disorder? A.Vital signs D The nurse is conducting a home visit for a 6-year-old client who has myoclonic and absence seizures. The parents are following a ketogenic diet for the child. Which observation requires follow-up by the nurse? A.Parents administer medium-chain-triglyceride (MCT) oil as needed. C A client's husband asks, "What should I do if my wife has a seizure to keep her safe?" Which response by the nurse is correct? A."Monitor your wife's blood
pressure." C A client is having a seizure. Which nursing intervention is of immediate importance? A.Administering medication B A patient has a tonic-clonic seizure while the nurse is in the patient's room. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. D An elementary teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach anymore, it will be too upsetting if I have a seizure at work." Which response by the nurse is best? a. "You may want to contact the Epilepsy Foundation for assistance." D Which action will the nurse take when evaluating a patient who is taking phenytoin (Dilantin) for adverse effects of the medication? a. Inspect the oral mucosa. A The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to a. assess the patient for a possible head injury. A Which of these prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. D When the home health RN is planning care for a patient with a seizure disorder, which nursing action can be delegated to an LPN/LVN? a. Make referrals to appropriate community agencies. B When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room (select all that apply)? a. Siderail pads ACD Which characteristic of a patient's recent seizure indicates a partial seizure? A. The patient lost consciousness
during the seizure. B The patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. You immediately assess the patient for A. an aura. B During the postictal period of a seizure, you would expect the patient to A. demonstrate minor jerking and eye fluttering. B You recognize that status epilepticus is a medical emergency because A. seizures continue without a return of consciousness. A The patient is seen in the clinic due to an increase in the frequency of seizure activity. In addition to a thorough health history you should draw blood for A.
anemia. B Treatment of status epilepticus requires initiation of a rapid-acting antiseizure drug that can be given intravenously. You would anticipate which drugs to be administered (select all that apply)? A. phenytoin (Dilantin) CD A male client is having a tonic-clonic seizures. What should the nurse do first? a. Elevate the head of the bed. D The nurse is caring for a child who had a seizure 15 minutes after sustaining a head injury. After assuring a patent airway, which of the following is the priority intervention? 1 Assess fluid and electrolyte status 2 The nurse provides information to the caregiver of a 68-year-old man with epilepsy who has tonic-clonic seizures. Which statement, if made by the caregiver, requires further teaching? A. "It is normal for a person to be sleepy after a seizure." B The nurse is providing instructions to a client with a seizure disorder who will be taking phenytoin (Dilantin). Which statement, if made by the client, would indicate an understanding of the information about this medication? 1."I need to perform good oral hygiene, including flossing and brushing my teeth." 1 The patient with type 1 diabetes mellitus with hypoglycemia is having a seizure. Which medication should the nurse anticipate administering to stop the seizure? A. IV dextrose solution A The nurse giving discharge teaching for a client receiving carbamazepine (Tegretol) should include: A. Monitor blood glucose, and report decreased levels. D The nurse completes a history and physical on a client admitted with exacerbation of a seizure disorder. What datum collected by the nurse requires intervention? A.History of asthma C The client, age 8, is prescribed valproic acid (Depokene) for treatment of a seizure disorder. The nurse should monitor the client closely for: A.Vitamin B deficiency. B The nurse should question the use of barbiturates for the treatment of seizure activity if prescribed for which of the following clients? A. 30-year-old pregnant female A A client receiving phenytoin (Dilantin) has been experiencing fluctuating serum blood levels of the medication. Development of which symptoms in the client should prompt the nurse to notify the primary health care provider immediately? (Select all that apply.) A. GI cramping and diarrhea BD Sets found in the same folderSpinal Cord Injury NCLEX Questions53 terms amylauren412 Seizures NCLEX12 terms murkacat Diabetes NCLEX questions71 terms szentler Evolve: School-Aged Children297 terms ican3 Other sets by this creatorAti: Evidence-Based Practice Q715 terms Godownme ATI Managing Client Care Q79 terms Godownme ATI Priority-Setting Frameworks Test Q715 terms Godownme ATI Safety Q720 terms Godownme What precautions should be implemented for a patient at risk for developing seizures?Seizure precautions can include water and heat safety in the form of taking showers rather than baths and cooking on the back burner of the stove. It also may include minimizing the use of ladders and fall-proofing one's house.
What seizure precautions are needed for a patient in the hospital?Seizure precautions include patient bed in the lowest position with side rails padded, or if possible, the mattress should be placed on the floor. Suction and oxygen equipment must be available at the patient's bedside. In some patients, environmental stimuli may trigger a seizure.
How do you handle a patient with status epilepticus?Refractory status epilepticus should be treated with a continuous infusion of an antiepileptic drug. Choices include an intravenous (IV) infusion of midazolam, pentobarbital, thiopental, or propofol (propofol infusion should not be used in children due to the risk of propofol infusion syndrome).
What are some seizure precautions?Take frequent breaks and drink plenty of water. Wear protective clothing (elbow or knee pads, helmet, protective eyeglasses or goggles) whenever possible. Avoid busy streets when bike riding; ride on bike paths or side streets. Always wear a medical ID bracelet or necklace, or carry a medical ID card.
|
Which seizure precautions would the nurse implement when admitting a patient with new onset status epilepticus?
zusammenhängende Posts
Urheberrechte © © 2024 paraquee Inc.
