seizures practice test key

N212 Medical Surgical Nursing 1

Seizures Key

An Emergency Occurs

A man sitting across from Alanna starts having a seizure. His entire body is rigid, his arms and legs are contracting and relaxing, and he is making guttural sounds. Alanna yells for the nurse, who immediately comes into the waiting room.

1. Which action should the nurse implement first?

A) Push the furniture away from the client. The nurse does need to protect the client from injury so moving furniture will help ensure that the client does not hit something accidentally. However, this is not the first intervention.

B) Remove people from the waiting room. The nurse should shield the client from onlookers but this is not the most important action to implement.

C) Assess the client's blood pressure. Assessment is important but when the client is having a seizure the nurse should not touch the person. Assessment will be completed after the seizure activity has ended.

D) Safely move the client to the floor. CORRECT The client in the chair must be brought safely to the floor so that he will have room to move his extremities and not injure himself during the seizure. It is not safe to leave a client having a generalized tonic-clonic seizure in a chair.

After initial interventions are implemented, the man continues to have a tonic-clonic seizure.

2. What action should the nurse implement next?

A) Insert an oral airway into the client's mouth. Once the seizure has started the nurse should not attempt to put anything in the mouth. The jaws are clenched and attempting to insert an oral airway could injure the client.


B) Determine if the client is incontinent of urine. The nurse should assess for bowel and bladder incontinence but this is not the most immediate priority.

C) Note the time and assess the type of seizure. CORRECT Accurate assessment by the nurse during the seizure provides important data used in determining the area in which focal activity originates, the area of the brain involved, and the type of seizure. It is important to document whether the beginning of the seizure was observed.

D) Notify the neurologist of the client's seizure. The neurologist must be notified of the seizure but this is not the nurse's next action.

After the man's seizure activity stops he is moved to a private room. The client had a seven minute seizure, has no apparent injuries and is oriented to name, place, and time, but is very lethargic.

3. Which intervention should the nurse implement?

A) Perform a complete neurological assessment. The nurse should make sure the client is breathing and has no injuries. There is no need to perform a complete neurological assessment.

B) Transfer the client to the emergency department. As long as the client has stopped seizing, is oriented, and has not sustained any injuries, there is no need to transfer the client to the emergency department.

C) Turn him to the side and allow the client to sleep. CORRECT During the postictal phase the client is very tired and should be allowed to rest quietly and sleep; placing the client on the side will help maintain a patent airway and prevent aspiration.

D) Interview the client to find out what caused the seizure. Interviewing the client can wait until the client has recovered from the seizure. Once the gentleman with the seizure is taken to the private room, the other people are brought back into the waiting room. Alanna sits down and after 20 minutes is called back to the neurologist's office.

Assessment


The nurse asks Alanna why she has been referred. Alanna reports that two weeks ago her roommate found her passed out on the floor. Alanna states she could not remember what happened but thought it might be because she had not been eating right. Then last week Alanna's roommate found her making unusual sounds and noticed that her arms and legs were jerking. At that time she was taken to the emergency department. She has her emergency room records and her past history medical records from her family healthcare provider.

4. To help determine why the seizure activity started, which question should the nurse ask Alanna?

A) "Have you ever had any type of head injury?" CORRECT Head trauma is a possible cause for the new onset of seizure activity.

B) "Are you currently taking any type of illegal drugs?" Illegal drugs are not a typical cause for seizure activity.

C) "Is there any chance that you may be pregnant?" Pregnancy alone does not increase the client's risk for a seizure unless the woman is diagnosed with eclampsia.

D) "Does anyone in your family have seizure disorders?" Seizure activity is not hereditary.

Alanna responds to the nurse's questions, and then tells the nurse that someone has been talking to her about seizures and asked her if she had aura with her seizure. She asks the nurse, "What is an aura?"

5. Which response by the nurse is correct?

A) "It is a visual or auditory warning that the seizure is about to start." CORRECT An aura is a visual, auditory, or olfactory occurrence that occurs prior to a seizure which warns the client that the seizure is about to occur. The aura often allows time for the client to fall to the floor or find a safe place to have the seizure.

B) "Auras occur when you are physically and physiologically exhausted." An aura is not dependent on the client being physically or physiologically exhausted.

C) "If you had an aura you would know what it is." This is not a therapeutic response. The nurse is not addressing the client's question.


D) "Auras do not occur with the type of seizures that you are having." This is incorrect information.

Alanna tells the nurse she remembers hearing a buzzing sound, and then the next thing she knew someone was waking her up. The neurologist comes into the room and completes Alanna's history and physical along with the nurse. With Alanna's history, the neurologist thinks that Alanna has had seizure activity and wants to determine exactly what is causing the new onset of seizure activity.

Diagnostic Tests

The neurologist schedules Alanna for an electroencephalogram (EEG) and a magnetic resonance image (MRI) to help evaluate Alanna's seizure disorder. The nurse discusses the tests with Alanna.

6. Which action should the nurse include in preparing Alanna for the EEG?

A) Advise the client not to eat anything 12 hours prior to the procedure. Meals are not withheld because an altered blood glucose level can cause changes in brain wave patterns. Caffeine-containing foods should be withheld since they will stimulate brain waves.

B) Instruct the client to refrain from consuming caffeine prior to the EEG. CORRECT Ingestion of caffeine will cause a stimulating effect to the brain.

C) Explain there will be some discomfort during the procedure. The test is painless and is performed while lying on a bed.

D) Determine if Alanna has any allergies to iodine or shellfish. This diagnostic test does not require the injection of any type of dye or contrast medium.

Alanna appears overwhelmed with all the information the neurologist discussed with her. She asks the nurse, "I don't understand why the neurologist is ordering an MRI."

7. Which statement by the nurse is the best response?

A) "The test will rule out many possible causes of seizures." CORRECT


An MRI can determine the presence of a tumor, congenital lesions, edema, infarct, hemorrhage, arteriovenous malformation, or a structural deviation that may be the cause of the seizures.

B) "An MRI can help determine the focal origin of the seizure." A complete neurological examination can help determine the focal neurological deficit or the focus or origin of the seizure activity.

C) "This test will identify elevated protein levels in the brain." A lumbar puncture will help determine if there are elevated protein levels in the cerebrospinal fluid; there is not a test that identifies protein levels in the brain tissue.

D) "It will confirm the seizure diagnosis and localize the lesion." The electroencephalogram helps confirm the diagnosis and localize the lesion.

Medication Teaching

The neurologist informs Alanna that no brain tumor, infection, or trauma was found but she did have seizure brain wave activity during the EEG. This brain activity is indicative of Epilepsy. The neurologist prescribes phenytoin (Dilantin), an anticonvulsant, to help prevent the seizure activity. The clinic nurse teaches Alanna about the medication, its side effects, and the need to take it every day.

8. Which statement indicates that Alanna understands the client teaching?

A) "I must brush and floss my teeth after every meal." CORRECT Gingival hyperplasia is a common occurrence in clients taking Dilantin. Thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care are essential to prevent this complication.

B) "I will have to check my medication level daily." A serum (venipuncture) Dilantin level is checked monthly at first then every six months once a therapeutic level is attained.

C) "My stool may be clay-colored while taking this drug." Clay-colored stool indicates liver problems which should be reported to the healthcare provider.

D) "I will not have seizures since I am on this medication." Medication does not ensure that the client will not have seizures. In some instances medication dosage may need to be adjusted or the client may need another medication.


The nurse continues to teach Alanna about the newly prescribed anticonvulsant medication.

9. Which instruction should the nurse include in the teaching session?

A) Decrease alcohol intake while taking this medication. The client should not drink any type of alcohol when taking anticonvulsants.

B) Take the medication with milk or milk products. Milk or milk products will decrease the absorption of the medication in the stomach.

C) Notify the office if experiencing muscle uncoordination. Anticonvulsant drugs may at first cause muscle uncoordination but the effects usually disappear after continued therapy.

D) Avoid hazardous tasks until the drug has been regulated. CORRECT These medications may cause drowsiness, decreased mental alertness, and dizziness at first. With continued therapy these symptoms usually disappear or the dose may have to be changed.

Therapeutic Communication

During the teaching session, Alanna shares with the nurse that she is very scared because she really doesn't remember having the seizure. She states that she had never seen someone with a seizure until the other day in the neurologist's office. Illness has never been part of her life and she doesn't feel sick now.

10. Which response by the nurse is most therapeutic?

A) "You should contact the Epilepsy Foundation. I think it will help." Referrals are indicated but Alanna is expressing feelings of being overwhelmed. Therefore a referral is not the most therapeutic response at this time.

B) "This is all new to you, and you must be frightened. Let's talk for awhile." CORRECT The nurse acknowledges Alanna's feelings and encourages her to continue to ventilate her feelings.

C) "Because you don't feel bad doesn't mean you won't have a seizure."


While this response teaches Alanna more about the disease, it does not address Alanna's fears.

D) "I know seeing someone having a seizure is a frightening experience." While this statement acknowledges Alanna's fear at seeing the seizure, it is not the most therapeutic response.

Alanna shares that she is worried about being able to have children. She doesn't have a boyfriend right now but someday wants to get married and raise a family.

11. The nurse's response should be based on which scientific rationale?

A) Research shows that women with epilepsy have a more difficult time conceiving. There is no research that reports that women with a seizure disorder cannot get pregnant.

B) Anticonvulsant therapy is contraindicated in pregnancy. Although some anticonvulsants cause fetal malformations, there are anticonvulsants that can be safely used during pregnancy.

C) Epilepsy does not prevent women from having children. CORRECT Alanna will need preconception counseling when considering child birth. She will require special care and guidance before, during, and after pregnancy.

D) Genetic counseling is needed for women with epilepsy. There is no data supporting a strong genetic component for epilepsy. Epilepsy may be idiopathic, secondary to birth injuries, infection, vascular abnormalities, or trauma.

Health Promotion

Education is the key to treating epilepsy. The office nurse teaches Alanna about how to reduce the incidence of seizure activity and how to promote safety during a seizure.

12. Which health promotion activity should the nurse discuss with Alanna?

A) Take tub baths rather than showers. Showers, rather than tub baths are safer because showers reduce the risk of drowning if a seizure occurs.


B) Be sure to exercise outside rather than in a gym. Exercise should be done in moderation in a temperature-controlled environment to avoid excessive heat.

C) Learn to identify seizure triggers. CORRECT Factors that may trigger seizures are abrupt withdrawal from medication, constipation, fatigue, fever, and sounds and sights such as television, flashing videos, and computer screens.

D) Take an anticonvulsant when an aura occurs. The client should take anticonvulsant medication daily to obtain a therapeutic serum level to help prevent seizure activity. There is no anticonvulsant that can be taken when an aura occurs that will prevent the seizure.

Alanna tells the nurse that she was on her "period" or getting ready to start her "period" both times she had a seizure. She shares with the nurse she is really worried about having a seizure the next time she menstruates.

13. How should the nurse respond?

A) "You are concerned about having a seizure when you start your period." Restating, a therapeutic communication technique, is not the best response in this situation, when the client has clearly expressed her concern and is seeking information.

B) "Are you currently taking any type of birth control pill or using the patch?" Birth control pills and patches are not known to cause or affect seizure activity.

C) "Your menstrual cycle can cause seizure activity due to hormone levels." CORRECT The onset of menstruation can cause seizure activity due to increased hormone levels that alter the excitability of neurons in the cerebral cortex. The client should be instructed to keep a record to determine if this pattern continues.

D) "The menstrual cycle does not usually affect your seizure activity." This information is incorrect.

14. Which statement by Alanna indicates that teaching provided by the nurse has been effective?


A) "I should move back home with my parents." This statement indicates that Alanna does not think she can live independently. Therefore more teaching is needed to empower her to accept her seizure disorder and live a productive life for a 23-year-old woman.

B) "I will carry a Medic Alert band at all times." CORRECT Alanna should carry a band or card at all times so her medical condition will be easy to identify.

C) "I do not think that I need to go to any support groups." The nurse should encourage Alanna to attend support groups which help clients have a healthy adaptation to the chronic condition.

D) "It is important for my family to get checked for epilepsy." Epilepsy does not have a strong genetic component and is no more prevalent in the Jewish population than any other culture.

Legal Issues

Two months after being diagnosed with the seizure disorder, Alanna calls the office and tells the nurse that her job supervisor has informed her that she is going to be let go because of her seizure disorder. Alanna is very upset and tells the nurse that she has been working at the same department store since she was 18-years-old.

15. Which statement reflects that the nurse understands the legal ramifications of the employer's action?

A) "The Epilepsy Foundation of America will help you keep your job." This organization has a training and placement service for individuals who need jobs but has no legal authority.

B) "I was afraid this might happen. Legally employers do not have to let you work." Employees have legal rights according to the federal government just like the employer has legal rights.

C) "You should take a copy of your medical records to your employer's personnel office." The personnel office does not need a copy of Alanna's medical records.

D) "According to the Americans with Disabilities Act, your employer cannot terminate


you." CORRECT The 1990 Americans with Disabilities Act states that employers must evaluate an employee's ability to perform the job and may not discriminate on the basis of a disability.

While talking on the phone, Alanna asks the nurse about driving her car. She states that she has not been driving due to the medications but hasn't had a seizure in two months and is not drowsy. She asks if she can start driving her car.


A) "You need to contact the Department of Transportation to find out the state laws." CORRECT Each state has laws concerning individuals with a seizure disorder having a driver's license. Some states will allow a driver's license after being seizure free for six months to two years. Many states require letters from the physician or nurse practitioner.

B) "You should not drive your car. Can't you keep taking the bus or train?" This response does not give Alanna any hope of ever being independent enough to drive a car and may not be correct information.

C) "I don't think you would want to be responsible for causing a car accident." This is a negative statement and does not address Alanna's question.

D) "I want you to make an appointment to come see me and we can talk." The nurse can effectively respond to this question over the phone.

Support Group Meeting

Alanna, her roommate, and her parents decide to attend an epileptic support group meeting that is held monthly at the local hospital. The topic for tonight is leisure activity and living with epilepsy. A clinical nurse specialist is the guest speaker for the group. One of the group members asks the nurse, "Is it okay for me to swim at the local YMCA?"

17. Which statement is the nurse's best response?

A) "Research shows that cold water causes seizures more than warm water." There is no research that shows the temperature of water causes seizures.

B) "Someone should be with you that knows what to do if you have a seizure." CORRECT


The Epilepsy Foundation states there is no reason why people with epilepsy should not participate in swimming as a leisure activity; however it is recommended that a swimming partner be present who is knowledgeable about what to do during a seizure.

C) "Before attempting to go swimming, you should consult with your healthcare provider." There is no need to discuss this activity with the healthcare provider. However, if the client has uncontrollable seizures then swimming should be discouraged.

D) "Swimming is one activity that people with epilepsy should plan to avoid." Swimming does not typically need to be excluded from leisure activity.

Another member of the group asks if there are any activities that should be avoided.


A) "Mountain climbing is an example of an activity to avoid." While this activity is potentially dangerous, all people with epilepsy do not need to avoid mountain climbing. It is essential, however, that the safety of everyone involved is considered.

B) "It really depends on how well your epilepsy is controlled." CORRECT If seizures are well-controlled there are no specific contraindications to any activity. However, if seizures are still occurring it is probably advisable to avoid some sports and activities.

C) "As long as safety gear is worn you can do any activity." Safety gear is important but does not ensure that the person will not be injured or die during a seizure.

D) "Epileptics should not participate in any contact sports." Generally, people with epilepsy are able to take part in contact sports such as rugby, football, and hockey as long as normal safeguards are followed. Boxing should be avoided.

The group leader shares that participation in any leisure activity requires weighing the risks against the benefits that the activity provides. Safety of the individual with epilepsy as well as the others participating in the activity is of the utmost importance.

When the group meeting is over, Alanna privately asks the nurse, "When is the best time to tell a potential boyfriend I have a seizure disorder?"

19.


If the nurse believes in the ethical principle of veracity for the client, how should the nurse respond?

A) "I would recommend waiting until it becomes more serious." This response does not reflect veracity.

B) "That is a hard question to answer. I am not sure I know the right answer." This response avoids the client's question.

C) "You should tell him the truth on the first date so he will know." CORRECT Veracity is truth-telling, and is reflected by this response.

D) "You are worried about how to tell your boyfriend you have epilepsy?" This is a therapeutic response addressing her feelings but does not reflect the ethical principle of veracity.

An Emergency Occurs

Three weeks after the phone call to the office nurse, Alanna is transported to the emergency room by an ambulance, accompanied by her roommate. Her roommate states, "She was watching television and had a seizure. As soon as the first seizure stopped, she started having another seizure, so I called 911." Alanna is lying on the stretcher with her eyes closed but there is no seizure activity at this time.

20. Which intervention should the nurse implement first?

A) Assess the client's vital signs. The nurse will need to assess the client's vital signs but in this situation this is not the first intervention.

B) Obtain a serum phenytoin (Dilantin) level. Obtaining a serum Dilantin level is indicated but there is a more immediate priority.

C) Ensure suction equipment is at the bedside. CORRECT The client will be very tired and want to sleep after a seizure and maintaining a patent airway is priority. Suction equipment should be available in case the client aspirates or starts choking. Remember Maslow's Hierarchy of Needs. Airway is always first.


D) Apply a cardiac telemetry monitor. Monitoring the client's cardiac rhythm is indicated but it is not the priority intervention.

Alanna's serum phenytoin (Dilantin) level is 7 mcg/ml. She has intravenous fluids of 5% Dextrose in Water (D5W) infusing at 100 ml/hour in the left forearm. The emergency room physician prescribes phenytoin (Dilantin) 25 mg intravenous push.

21. Which action should the nurse implement?

A) Question the prescription since 7 mcg/ml is above the therapeutic level. The therapeutic Dilantin level is 10 to 20 mcg/ml.

B) Dilute the medication and flush the tubing before and after with normal saline. CORRECT Dilantin is not compatible with any fluid except normal saline; the nurse should flush the IV before and after with normal saline only.

C) Administer the medication undiluted in the port closest to the intravenous site. Administering Dilantin in this manner may result in a life-threatening complication.

D) Determine the time when Alanna took the last oral dose of her Dilantin. This information will not affect the administration of this medication.

An hour later, Alanna is awake and alert. She does not remember what happened but remembers hearing a buzzing sound. The next thing she remembers is waking up in the emergency room.

22. Which question is most important for the nurse to ask Alanna?

A) "Why did you quit taking your medication?" This question may be perceived as judgmental and challenging, and may be based on an inaccurate assumption. This will not help develop a therapeutic relationship between Alanna and the nurse.

B) "Have you been taking your medication regularly?" CORRECT Since the therapeutic Dilantin level is low, the nurse may infer that Alanna has not been taking her medication as prescribed. However, the nurse needs to clarify this inference, and then determine the reason before taking further action. It is important to question the client in a non-


threatening manner to obtain the needed information, which helps establish a therapeutic relationship.

C) "Were you under any type of stress the last week?" Stress may trigger a seizure but another question is more important.

D) "Are you currently on or just finished your period?" The menstrual cycle may trigger a seizure but another question is more important.

Alanna tells the nurse the medication just made her feel funny and she really didn't think she would have any more seizures so she quit taking it two weeks ago. Alanna is admitted into the hospital for observation.

Nursing Care

Alanna is admitted to the medical unit and her parents arrive a few minutes later. She is drowsy but arouses easily to verbal stimuli.

23. Which intervention should the nurse implement?

A) Ask if she wants her parents in the room. In the Jewish tradition, the parents are typically respected and very active in their children's lives even into adulthood. While Alanna is drowsy, she does arouse easily and can ask her parents to leave if she doesn't want them in the room.

B) Pad and elevate the side rails of Alanna's bed. CORRECT Alanna is at high risk for injury because of her recent seizure activity. Protecting her from injury by elevating and padding the side rails helps address Alanna's safety needs.

C) Place a padded tongue blade at the bedside. The nurse could place an oral airway at the bedside but once a seizure starts nothing should be placed in the client's mouth. A padded tongue blade should never be used since the client could bite down on the tongue blade and it could occlude the airway.

D) Attach a seizure precautions sign to the door. Due to confidentiality issues, placing signs on a client's door is not encouraged except when it impacts the safety of healthcare providers, such as for needed isolation precautions.


Alanna's mother tells the nurse that neither she nor her father have ever seen Alanna have a seizure. They have read all the information on epilepsy and have talked to Alanna and the neurologist about the seizures but are very worried about their daughter. The mother tells the nurse, "I don't think I would know what to do if I saw her have a seizure."


A) "The most important thing is to keep her from injuring herself." CORRECT Nothing can stop the seizure once it starts. Protecting the client from injury is the most important action to take.

B) "I know you would do the best that you could for your daughter." This statement does not help empower Alanna's parents. The nurse should help the family learn how to care for Alanna during the seizure.

C) "It helps if you restrain her arms so that she won't flail about." Restraining the client can cause injury to both the person having the seizure and the person trying to restrain the seizing client.

D) "You should make sure she takes her medication every day." Alanna is 23-years-old and must take responsibility for the management of her disease process; it is not the responsibility of her parents to make sure she takes her medications.

Cultural Issues

Alanna's primary nurse realizes that Alanna is of the Jewish faith and wants to provide culturally sensitive nursing care during her hospitalization.

25. Which statement reflects that the nurse is sensitive to Alanna's cultural needs?

A) "No one will interrupt you during Friday morning prayers." The Jewish holy day lasts from Friday night to Saturday night.

B) "The hospital chaplain will come visit you every day." Rabbis assist Jewish people with their spiritual needs. A hospital chaplain, typically of the Christian faith, can contact a rabbi at Alanna's request, but offering a daily visit by the hospital chaplain does not indicate the nurse understands the Jewish faith.


C) "Tell me about the type of Jewish teachings you practice." CORRECT Many people of the Jewish faith practice different teachings, some more Orthodox and some more liberal. Therefore the nurse needs to know about Alanna's practices to help meet her cultural needs.

D) "You can be moved to a room with another Jewish person." Room assignments are based primarily on clients' medical diagnoses rather than a shared culture.

Alanna later tells the nurse that she and her family do follow a kosher diet. The next morning, Alanna's parents arrive at the nurses' station with a kosher breakfast for Alanna, which includes a bagel, scrambled eggs, and a glass of orange juice. Alanna has no prescribed dietary restrictions.

26. What action should the nurse take?

A) Inform Alanna's parents that it would be better if they allowed their daughter to eat the food cooked by the hospital. Since Alanna's diet is not restricted, there is no reason she cannot eat foods brought by her family.

B) Exchange the food provided on the hospital tray with the kosher food and deliver the tray to Alanna's room. Place the meal that Alanna's parents brought onto the tray of food provided by the hospital and deliver the tray. Foods prepared following kosher rules should not be served on dinnerware used for non-kosher foods.

C) Return the tray provided by the hospital and ask the parents if they would like to take the meal they provided to Alanna's room. CORRECT This action supports Alanna's cultural food preferences and also ensures that the kosher foods do not come in contact with non-kosher foods, and are not inadvertently served on dinnerware used for non-kosher foods.

D) Offer to order additional guest trays from the hospital kitchen so that Alanna's parents can eat with her. Since the parents brought kosher food to the hospital, it is likely they are concerned that the hospital does not follow kosher rules for food preparation.

Discharge Home


Alanna is discharged from the hospital after two days. Her Dilantin level is 10.4 mcg/ml after receiving intravenous Dilantin. Alanna's neurologist is changing Alanna's anticonvulsant from Dilantin to valproic acid (Depakote) to reduce possible side effects and increase her compliance with medication administration.

27. Which action should the nurse include when providing discharge teaching regarding the new medication?

A) Explain to the client that many clients get a rash that will go away with time. A skin rash is an adverse reaction and should be reported to the healthcare provider.

B) Advise the client that, unlike Dilantin, drug levels will not need to be checked. The therapeutic level of Depakote is 50 to 100 mcg/ml which is monitored at least monthly initially and then every six months.

C) Instruct the client to take this medication on an empty stomach to help with absorption. This medication can be taken with food to help decrease gastric irritation.

D) Discuss with the client the importance of having liver function tests while on this medication. CORRECT This medication is heptotoxic so liver function tests are monitored at follow-up visits.

Prior to Alanna's discharge the nurse evaluates the client teaching provided during this hospitalization.

28. When planning care, which client teaching goal is most important when determining Alanna's understanding? The client will

A) Agree to attend support group meetings regularly. Attendance at support groups is highly recommended but this is not the most important goal for the nurse to evaluate during discharge teaching.

B) Have no seizure activity for the next six months. This long-term goal evaluates the client's compliance with the plan of care, but cannot be evaluated at the time of discharge.

C) Describe five strategies to prevent seizure activity. CORRECT A correct description of the needed information is the best way to evaluate if teaching was effective. Remember goals must be measurable. Stating the correct dosage, side effects, when to


call the healthcare provider, and the importance of follow-up visits are appropriate goals when evaluating the effectiveness of client teaching.

D) Demonstrate how to correctly take her medication. Putting a tablet/capsule in the mouth does not evaluate Alanna's understanding of the discharge teaching.

Case Outcome

Alanna continues to work as a sales clerk, plans to graduate from college next semester and remains active in the Shalom Synagogue. She, her roommate, and her parents attend the monthly Epilepsy Support Group at the local hospital. The new anticonvulsant, Depakote, does not make her feel funny and she takes it faithfully. With her positive attitude toward life, her strong Jewish faith, and the support of her family and friends she intends to live a very full and productive life. And, by the way, she met a very nice young Jewish man, told him about her epilepsy, and they are now engaged to be married.

A nurse has been assigned to care for a client diagnosed with Menier's disease. Which of the following precautions should the nruse inform the assistive personnel (AP) about prior to the AO providing morning care?a. Remove scopolamnine patch during bath careb. Encourage high intake of fluidsc. Ensure adequate lighting by keeping curtains opend. Observe the client for dizziness when ambulating

Answer:

D - Clients who have Meniere's disease experience the triad of symptoms - tinnitus,

unilateral hearing loss, and vertigo. Instruct the AP to observe the client for dizziness when

ambulating the client. Do not remove the scopolamine patch, which is used to treat

dizziness, during bath care. A high intake of fluids and birght lights may exacerbate the

symptoms.

A client has been experiencing mild to moderate veritgo due to benign paraoxysmal vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo? SELECT ALL THAT APPLYa. Take prescribed meclizine hydrochloride (Antivert)b. Move head slowly when changing positionsc. Avoid fruits high in potassiumd. Use stress-management techniquese. Avoid beverages that contain caffeine

Answer:


a, b, d, e - Meclizine is an effective pharmacologic treatment for vertigo. Moving the head

slowly when changing positions and stress management techniques can all lessen the

incidence of vertigo. Instruct clients to avoids bevereages that contain caffeine. Foods high

in potassium have no effect on vertigo.

A client is newly fitted with a hearing aid. Which of the following client statements indicates a need for intervention by the nurse?a. "I have difficulty hearing in a loud environment."b. "I wash the earppiece of my hearing aid with alcohol."c. "I keep my hearing aid turned down low."d. "I turn my hearing aid off at night."

Answer:

B - The earpiece of a hearing aid should be cleaned with mild soap and water, not alcohol.

A nurse is caring for a client in an extended care facility who has been diagnosed with sensorineural hearing loss. Which of the following findings in the client history are possible causative factors for the hearing loss? SELECT ALL THAT APPLYa. Age 81b. History of vancomycin antibiotic therapyc. Working with heavy artillary in the Army 60 years agod. Presbyopiae. Daily use of warfarin (Coumadin)f. Presbycusisg. History of IV furosemide (Lasix) therapy for heart failure

Answer:

All the above factors can contribute to hearing loss except daily use of warfarin, an

anticoagulant, and presbyopia, which is loss of near vision between the ages of 40-50.

Identify unexpected findings for the Weber and Rinne tests

Answer:

Weber test: Lateralizatoin indicating the sound is heard loudest in one ear

Rinner test: Bone conduction is longer than air conduction

A nurse is caring for a client in an extended care facility who has macular degeneration. With which of the following ADLs will the client require the greatest amount of assistance?a. Dressingb. Eatingc. Toiletingd. Ambulating

Answer:


B - A client with macular degeneration experiences distorted or loss of vision consistent with

involvement of the macula, a part of the retina. This affects a client's central vision making

activities such as eating very difficult. While the client may require assistance with dressing,

toileting, and ambulating, peripheral vision is usually still intact and the use of visual

scanning may be adequate to perform theses activities with minimal assistance.

A nurse is reinforcing teaching for a client who has just had a cataract removed from the right eye and an intraocular lens implanted. Which of following should the nurse include? SELECT ALL THAT APPLYa. Wear sunglasses when outsideb. Do not engage in sexual intercourse until your provider has verified that your eye has healedc. You may wah your hair as soon as you go homed. You will no longer need glassese. Manage eye with acetaminophenf. Take a stool softener to prevent constipation.

Answer:

a, b, e, f - The client should be instructed to wear sunglasses when outside or in bright

plaecs for at least a week. Activites that cause the client to perform the Valsalva maneuver,

such as sexual intercourse and bearing down for a bowel movement, can increase

intraocular pressure and should be avoided. Eye pain should be mild after cataract removal,

so pain should be managed with acetaminophen. If the pain is unrelieved, the client should

report to the provider. Hair should not be washed in the shower for at least a week after the

surgery, and glasses will be needed to correct vision to 20/20

A nurse is collecting fata for a client who has a detached retina of the left eye. Which of the following will the nurse expect the client to report?a. Severe left eye painb. Seeing floating dark spotsc. Gradual loss of visiond. Inflamed conjuctival sac

Answer:

B - The onset of retinal detachment is abrupt. The client may report seeing floating dark

spots, bright flashes of light, and a "curtain closing" over the visual field. A detached retina is

usually painless, the onset is abrupt, and there are no signs of infection or inflammation.

If the client has presbyopia, what visual deficit should the nurse expect the client to report?

Answer:

the client will have an inability to focus on objects up close. Often, the client the report a

headache and eye fatigue while focusing on objects up close. Instruct the client to hold

reading materials at an arm's length.


Which of the following are possible causes of the client's reduced vision?a. Presbyopiab. Cataractsc. Glaucomad. Retinal detachmente. Retinopathy

Answer:

b, c, e - Some possible causes of the client's reduced vision include cataracts, glaucoma,

and retinopathy. Presbyopia causes decreased vision during the fifth decade of life and

retinal detachments cause immediate loss of vision.

A nurse caring for a client who has myastehnia gravis has reinforced instructions about actions that should be taken to decrease the risk of commplicatoins secondary to MG. Which of the following client statements indicates a need for further teaching?a. "I should take my Mestinon 1 hour before or 2 hours after a meal."b. "I have suction equipment at home in casee I get really choked."c. "I will make sure I schedule at least a couple of rest periods during the day."d. "I will put thickener in fluids that I drink when I am feeling very tired."

Answer:

Medication used to treat MG should be taken 45 min prior to a meal to help strengthen the

muscles used when swallowing and prevent aspiration. Keeping suction equipment

available, taking rest periods during the day, and putting thickener in fluids when tired, are all

measures that will prevent complications due to aspiration or falls.

A nurse is caring for a client who has myasthenia gravis (MG) and eperiences ptosis. Which of the following actions should the nurse take to prevent complications secondary to ptosis?a. Avoid using eye dropsb. Support neck with pillowsc. Tape eyes shut at nightd. Encourage frequent position changes

Answer:

C - Ptosis is drooping of the eyelid caused by weakness of the muscles of the eyelids. This

weakness can cause the eyelids to not close completely making them at risk for corneal

dryness and deterioration. Application of lubricating drops and taping the eyes shut at night

will help protect the corneas from dryness. While the client may benefit from supporting the

neck with a pillow and frequent position changes, these actions do not prevent complications

due to ptosis.


A nuse is collecting data on a client in a rehabilitation unit who was diagnosed with Guillain-Barre Syndrome 1 month ago. The client ask the nurse if he will ever walk again. Which of the following is an appropriate response?a. "Since you have not shown any improvement by now, it is doubtful."b. "Your recovery will be quicker if you work hard in physical therapy."c. "Most individuals do walk again, but it may take up to two years."d. "It is best if you ask your physical therapist that question."

Answer:

Clients with GBS usually begin to show significant improvement within 4-6 months. However,

in severe cases, recovery can take up to 2 years. Options A and D are nontherapeutic

repsponses and dismiss the client's concerns. A client's rate of recovery is bassed on the

rate and amount of remyelination necessary for normall nerve conduction to resume. Even if

the client works hard in thearpy, remyelination must occur for improvement in muscle

innervations.

A nurse is collecting data on a client in a rehabilitation unit who was diagnosed with GBS 1 month ago. Which of the following client findings should the nurse anticipate? SELECT ALL THAT APPLYa. Muscle weaknessb. Muscle atrophyc. Incontinenced. Ineffective coughe. Hyperreflexia

Answer:

a, c, d - A characteristic of GBS is muscle weakness without atrophy. Incontinence and

ineffective cough are likely due to muscle weakness. Relexes are decreased or absent.

A nurse is helping to admit a client to a medical unit whose preliminary diagnosis is Guillain-Barre syndrome (GBS). Which of the following client reports is relevant in regard to the diagnosis of GBS?a. Recent head traumab. History of systemic lupus erythematosusc. Gastrointestinal (GI) virus 2 weeks agod. Recent tick bite

Answer:

C - A history of an upper respiratory or GI infection, stress such as surgery/trauma, or recent

vaccination within the last 1 to 3 weeks is a common history finding in clients with GBS.

Head trauma, systemic lupus erythematosus, and tick bites are unrelated to GBS

A nurse is caring for a client with AD. The client needs assistance with dressing and grooming. This manifestation represents which of the


following stages of AD?a. Stage 3b. Stage 4c. Stage 5d. Stage 6

Answer:

D - In Stage 6 of AD, the client may have difficulty with the activites of daily living, including

dressing and grooming. In Stage 3, the client may have short-term memory loss. In Stage 4

of AD, the client may have difficulty with activites such as paying bills and managing money.

In Stage 5, the client may be disoriented to time and place.

A nurse is reinforcing teaching to an older adult client who has AD and his wife. The client has beeen prescribed donepezil (Aricept). Which of the following statements by his wife indicats an understanding of the teaching about the medication? SELECT ALL THAT APPLYa. "It should be taken in the morning before breakfast."b. "It should increase my husband's appetite."c. "It should help my husband sleep better."d. "It may cause diarrhea."e. "It should help my husband's daily function."

Answer:

Donepezil may cause diarrhea due to its cholinergic effects. It helps slow the progression of

AD. It can also help improve behavior and daily functioning. Donepezil should be taken once

a day at bedtime. It does not improve appetite or promote sleep.

A family member of a client who has Alzheimer's disease (AD) asks then urse about risk factors for AD. The nurse should inform the family member that which of the following are risk factors for AD? SELECT ALL THAT APPLYa. Ageb. Family historyc. Smokingd. Sun exposuree. Previous head injury

Answer:

a, b, e - Age, family history, and previous head injury are risk factors for AD. Although

smoking and excessive sun exporsure should be avoided, these activities do not put a client

at risk for AD

A nurse is caring for a client with meningitis. Which of the following findings during data collection should then urse immediately report to the provider?


a. Feverb. Report of photophobiac. Duskiness of nail beds of fingersd. Restlessness

Answer:

C - Using the airway, breathing, circulation (ABC) approach to client care, the priority finding

is duskiness of the nail beds because this finding may indicate that septic emboli are

compromising the circulation to the extremities, which can cause gangrene and loss of

fingers and toes. Fever, report of photophobia, and restlessness are all findings that should

be reported, but they are not the priority finding.

A nurse is assisting an RN admit a client who is diagnosed with bacterial meningitis from Neisseria meningitidis. Which of the following isolation precautions should the nurse implement to prevent transmission of the disease?a. Wear gloves upon entering the roomb. Place the client in a room with negative airflow exchangesc. Wear a mask when standing at the bedside of the clientd. Place an N-95 HEPA filter mask on the client when transportation outside the room occurs.

Answer:

Droplet precautions are required for clients who have meningitis caused by Neisseria

meningitides. When droplet precautions are required, a mask must be worn when within 3 ft.

of the client. Gloves are worn as standard precautions, but are not necessary upon entering

the room. A room with negative airflow exchanges is used forr clients who have diseases

transmitted by air or are airborne. An N-95 HEPA filter mask is also only owrn by persons

who enter the room of a client who has a disease transmitted by air.

A nurse is assisting an RN admit a client who is diagnosed with bacterial meningitis from Neisseria meningitidis. What associated risk factors may the client report to the nurse when collecting data? SELECT ALL THAT APPLYa. Residential living in a dormitoryb. Current treatment of asthma with corticosteroidsc. Report of being bitten by a tickd. History of otitis mediae. History of multiple mosquito bites while camping

Answer:

a, b, d - Clients who live in a communal setting, such as a dormitory, are at risk for

contracting bacterial meningitis if they ahve not been immunized. Bacteria-based infections,

such as otitis media and sinusitis, as well as medications that cause immunosuppression,


such as corticosteroids, can place a client at risk for bacterial meningitis. Mosquito bites

cause viral, not bacterial meningitis, and tick bites cause Lyme disease.

A nurse is assisting an RN admit a client who is diagnosed with bacterial meningtitis from Neisseria meningitidis. Which of the following findings should the nurse expect? SELECT ALL THAT APPLYa. Feverb. Photophobiac. Vomitingd. Hemiparesise. Bradycardia

Answer:

a, b, c, d - Fever, photophobia, and vomiting are important signs of bacterial meningitis.

Decreased muscle tone, hemiparesis, and hemiplegia may occur later in the course of the

illness. Tachycardia, not bradycardia, is an expected finding for a client with bacterial

meningitis.

A nurse is reviewing preoperative teaching with the family of a client who has a brain tumor and will undergo a craniotomy. What should be included in the teaching? Description of Procedure and Preoperative and postoperative interventions.

Answer:

A craniotomy is a surgical opening in the skull to expose brain tissue. It involves a comlete or

partial resection of the brain tumor

Nursing Interventions : Preoperative

Provide written explation, Remind client to stop taking aspirin at least 72hrs prior to

procedure, Review the need for a living will an durable power for health decisions,

Administer meds as prescribed (anxiolytics and muscle relaxants)

Nursing Interventions : Postoperative

Monitor vital signs and neurological status to include use of Glasgow scale, Maintain client's

head elevated to 30 degrees and in a neutral position to prevent increased ICP, Monitor for

postoperative blleding and seizures, Prevent client performing any straining activites (moving

up in bed, attempting to a bowel movement)

A nurse is reviewing the medical record of a client who is suspected of having a malignant brain tumor. The client has a presciptiont to test for Romber's sign. Which of the following actions should the nurse take to perform the test?

A. Stroke the lateral aspect of the sole of the foot.

B. Ask the client to blink his eyes.


C. Observe for facial drooping

D. Have the client stand erect with eyes closed.

Answer:

D - If a client loses his balance while attempting to stand erect with his eyes closed, he is

considered to have a positive Romberg sign.

Babinski's sign is elicited by stroking the lateral aspect of the sole of the foot.

Asking the client to blink his eyes measures and observing for facial drooping measures

cranial nerve function and is not part of the Romberg test

A nurse is caring for a client who has a benign brain tumor and who asks if this type of tumor will occur in other areas of his body. Which of the following is an appropriate response by the nurse?

A. "It can spread to breasts and kidneys."

B. "It can develop in you GI tract."

C. "It is limited to brain tissue."

D. "It probably started in another area of your body and spread to your brain."

Answer:

C - Benign brain tumors develop from the meninges or cranial nerves and do not

metastasize.

Benign brain tumors are not secondary to other types of tumors and do not metastisize

A nurse is reviewing a presciption for dexamethosone with a client who has an expanding brain tumor. Which of the following are appopriate statements by the nurse. (SELECT ALL THAT APPLY)

A. "It is given to reduce swelling of the brain."

B. "You will need to monitior for low blood sugar."

C. "You may notice weight gain."

D. "Tumor growth will be delayed."

E. "It can cause you to retain fluids."

Answer:

A - CORRECT: Dexamethasone is a comon steroid prescribed to reduce creebral edema

B - Incorrect: The client can experience hypergylcemia as an adverse effect dexamethasone

C - CORRECT: Weight gain is an adverse effect of dexamethazone


D - Incorrect: Dexamethasone does not affect tumor growth. It is given to prevent cerebral

edema

E - CORRECT: Fluid retention is an adverse effect of dexamethasone

A nurse is contributing to the plan of care for a client who has an open head injury. Which of the following should be included to prevent increased ICP? (SELECT ALL THAT APPLY)

A. Keep the head of the bed elevated 30degrees

B. Ensure SaO2 is greater than or equal to 92%

C. Have the client cough and deep breathe every 2 hr

D. Ensure the PaCO2 is kept at 45mmHg or greater

E. Encourage the client to assist when being pulled up in bed

Answer:

A - CORRECT: The head of the client's bed should be elevated approximately 30 degrees at

all times with the head in a neutral position

B - CORRECT: The SaO2 should be kept greater than or equal to 92% to ensure adequeate

perfusion of the brain

C - Incorrect: Coughing should be avoided to prevent increasing the client's intra-abdominal

pressure, which can increase ICP

D - Incorrect: Buildip of CO2 will cause vasodilation of the cerebral vessels causing

increased ICP

E - Incorrect: The client should avoid activites that cause neck felxion or increased intra-

abdominal pressure, such as pushing or pulling himself up in bed

A nurse is collecting data from a client who has a closed-head injury. Which of the following findings indicate increased ICP? (SELECT ALL THAT APPLY)

A. Disorientation to time and place

B. Restlessness and irritability

C. Unilateral facial paralysis

D. Unequal pupils

E. Headache

Answer:

A - CORRECT: Increased ICP can cause the client to become disoriented

B - CORRECT: ICP can cause behavioral changes, such as restlessness and irritability


C - Incorrect: Unilateral facial paralysis is not an expected finding with ICP

D - CORRECT: Unequal pupils indicate pressure on the oculomotor nerve secondary to

increased ICP

E - CORRECT: A headache is a manifestation of increased ICP

A nurse is caring for a client who has dysphagia. List 3 nursing actions the nurse should include while caring for this client.

Answer:

Nursing actions:

Maintain suction at the client's bedside

Monitor the client's gag reflex

If the gag reflex is present, five the client a small sip of water to determine if choking occurs

If the client exhibits some difficulty managing food or fluids, a speech therapist should

conduct a swallowing evaluation

Coordinate with an RN to provide the client's intial feedings, so appropriate interventions can

be taken if choking occurs.

Thicken liquids using the appropriate amount of thickener to obtain the prescirbed

consistency

A nurse is collecting data from a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?

A. Impulse control difficulty

B. Poor judgement

C. Inability to recognize familiar objects

D. Loss of depth perception

Answer:

C - A client who experienced a left-hemispheric stroke will demonstrate the inability to

recognize familiar objects, also known as agnosia

A client who has experienced a right-hemispheric stroke will experience difficulty with

impulse control, poor judgement, and a loss of depth perception

A nurse has been assigned a client who has global asphasia (both receptive and expressive). Which of the following interventions are appropriate to include in the client's plan of care? (SELECT ALL THAT APPLY)

A. Speak to the client at a slower rate.


B. Look directly at the client when speaking.

C. Allow extra time for the client to answer.

D. Complete sentences that the client cannot finish.

E. Give instructions one step at a time.

Answer:

A - CORRECT: Clients who have global asphasia will have difficulty with both speaking and

understanding speech. One strategy that can enhance client understanding is speaking to

the client at a slower rate.

B - CORRECT: One strategy that can enhance understanding while speaking is looking

directly at the client

C - CORRECT: One strategy that can enhance understanding is allowing the client extra

time to answer.

D - Incorrect: The nurse should allow the client adequate time to finish sentences and not

complete the sentences for him

E - CORRECT: One strategy that can enhance understanding is giving instructions one step

at a time

A nurse is contributing to the plan of care for a client who has dysphagia and has a new dietary presciption. Which of the following should the nurse include in the plan of care? (SELECT ALL THAT APPLY)

A. Have suction equipment available for use.

B. Thicken liquids using a commercial thickener

C. Place food on the unaffected side of the client's mouth

D. Instruct the client to swallow with her neck flexed

E. If choking occurs, let the client rest serveral minutes before continuing feeding.

Answer:

A - CORRECT: Suction equipment should be available in case of choking and aspiration

B - CORRECT: the client should be given thickened liquids, which are easier to swallow

C - CORRECT: Placing food on the unaffected side of the client's mouth will allow her to

have begtter control of the food and reduce the risk of aspiration.

D - CORRECT: The client should be taught to felx hern eck, tucking the chin down and

under, to close the epiglottis during swallowing


E - Incorrect: Due to the risk of aspiration, if the client shokes during a feeding, the client

should be make NPO and provider notified.

A nurse is contributing to the plan of care for a client who has heft homonymous hemianopsia. Which of the following is an appropriate nursing intervention?

A. Tell the client to scan to the right to see objects on the right side of his body.

B. Place the client's bedside table on the right side of the bed.

C. Orient the client to food on a plate using the clock method

D. Place the client's wheelchair on his left side.

Answer:

B - The client is unable to visualize to the left midline of his body. Placing the client's bedside

table on the right side of his bed will permit visualization of the items on the table

A client who has heft homonymous hemianopsia has lost the left visual field of both eyes.

Scanning to the right will decrease the client's field of vision. Using the clock method of food

placement will be ineffective bacause only half of the plate can be seen. The client's

wheelchair should be placed to the client's right, or unaffected side

A nurse in a long-term facility is collecting data from an older adult client who is being observed for a transient ischemic attack (TIA). Which of the following are manifestations of a TIA? (SELECT ALL THAT APPLY)

A. Unilateral numbness of the arm.

B. Stiff neck

C. Dizziness

D. Slurred speech

E. Otorrhea

Answer:

A - CORRECT: Intermittent unilateral numbness of the arm can indicate a TIA. Progressive

or worsening numbness can indicate a stroke.

B - Incorrect: Neck stiffness is not an indicator of a TIA

C - CORRECT: Periodic dizziness can indicate a TIA. Progressive or worsening can indicate

a stroke

D - CORRECT: Periodic slurred speech can indicate a TIA. Persistent or worsening slurred

speech can indicate a stroke

E. Incorrect: Otorrhea (leakage of spinal fluid from the ear) is not an indicator of TIA


A nurse is contributing to the plan of care for a client who is at risk for status epilepticus. What concepts should the nurse contribute to the plan of care? Define the condition, Describe 4 possible causes, Describe five actions during a seizure

Answer:

Status epilepticus is prolonged seizure activity occuring over a 30-min period

Causes: Withdrawal from alcohol, Withdrawal from antiepileptic meds, Infections, Fever

Interventions: Maintain patent airway, Provide oxygen, Monitor pulse oximetry, Assist with

emergency care (administering fluids, CPR)

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 factors should the nurse include? (SELECT ALL THAT APPLY)

A. High fat intake

B. Excessive fatigue

C. Acute alcohol intake

D. Decreased physical activity

E. Exposure to bright lights

Answer:

A - Incorrect: A high-fat diet is not a trigger for seizures

B - CORRECT: Excessive fatigue can trigger seizures

C - CORRECT: Acute alcohol intake can trigger seizures

D - Incorrect: Increase physical activity can lead to seizures

E - CORRECT: Exprosure to bright lights can trigger seizures

A nurse is providing discharge instructions to a client who has a new diagnosis of epilepsy and is to start taking phenytoin (Dilantin). Which of the following instructions should the nurse include? (SELECT ALL THAT APPLY)

A. "Remove caffeinated products from your diet."

B. "Wear a medical alert tag."

C. "Stop taking your medication if you have nausea."

D. "Take an extra dose of the medication if you forget a dose."


E. "Keep a seizure frequency diary."

Answer:

A - CORRECT: The nruse should instruct the client to avoid caffeinated products because

caffeine can trigger a seizure.

B. - CORRECT: The nurse should instruct the client to wear a medical alert tag so if he

experiences a seizure he will receive appropriate medical attention.

C - Incorrect: The nurse should not instruct the client to tstop taking his medication if he has

nausea because abrupt cessation of meds can result in a seizure. The client should take thte

meds with food to prevent nausea.

The nurse is caring for a client who just experience a generalized seizure. Which of the following actions should the nurse perform first?

A. Place the client in a side-lying position.

B. Request a prescription for seizure precautions

C. Reorient the client to the environment

D. Provide a quiet environment

Answer:

A - The greatest risk to the client is aspiration during the postictal phase. Therefore, the first

action the nurse should take is to place the client in a side-lying position so secretions can

drain from the mouth.

The nurse should request a prescription for seizure precautions to prevent further injury, but

this is not the first action the nurse should take. Reorienting the client to the environment is

important because the client may feel confused after a seizure, but not the 1st action. The

nurse should provide a quiet environment to allow the client to rest, but not the 1st action

A nurse is caring for 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. Move furniture away from the client

C. Loosen the client's clothing

D. Protect the client's head with padding

E. Restrain the client

Answer:

A -CORRECT: The nurse should implement privacy to minimize the client's embarrassment.

B - CORRECT:The nurse should move the furniture away from the client to prevent injury


C - CORRECT: Then nurse should loosen the client's clothing to minimize restriction of

movement

D - CORRECT: The nurse should protect the client's head from injury by placing the client's

head in the nurse's lap or using a pillow or blanket under the client's head during a seizure.

E - Incorrect: The nurse should not restrain the client, which may cause an injury or more

seizure activity

A nurse is caring for a client who is scheduled for a magnetic resonance imaging (MRI) scan with contrast dye. What actions should the nurse take? A definition of this diagnostic test. Identify 3 preprocedure actions, 1 intraprocedure action, and 1 postprocedure action.

Answer:

MRI - Magnetic resonance imaging scan relies on magnetic field to take multiple images of

the body

Nursing Actions Preprocedure:

Have client remove all jewlery, Determine if the client has claustrophobia, Question the client

concerning implants containing metal, Question the client regarding allergies

Intraprocedure: Stabilize the client's head

Postprocedure: Monitor for allergic reaction to the conrast dye during the MRI

A nurse is reinforcing teaching to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching?

A. "Do not wash your hair the morning of the procedure."

B. "Try to stay awake most of the night prior to the procedure."

C. The procedure will take approximately 15 minutes."

D. "You will need to lie flat for 4 hours after the procedure."

Answer:

B - The nurse should instruct the client to remain awake most of the night to provide cranial

stress and increase the possibility of abnormal electrical activity.

Then nurse should instruct the client to wash her hair on the morning of the procedure to

remove oils, gels, and sprays, which may affect the EEG readings. The nurse should inform

the client that the procedure will take approximately 1 hour. The nurse should instruct the

client that normal activity can resume immediately following the procedure.

A nurse is collecting data from a client who is scheduled for a cerebral angiogram with contrast dye. Which of the following statements by the


client dhould the nurse report to the provider? (SELECT ALL THAT APPLY)

A. "I think I may be pregnant."

B. "I take Coumadin."

C. "I take antihypertensive medication."

D. "I am allergic to shrimp."

E. "I am allergic to latex."

Answer:

A - CORRECT: The nurse should report the client' possible pregnancy because the contrast

dye may place the fetus at risk.

B - CORRECT: The nurse should report that the client is taking Coumadin due to the

potential for bleeding following the angiogram.

C - Incorrect: The nurse should understand that there is no conraindication related to

contrast dye for a client who is taking antihypertensive medication

D - CORRECT: The nurse should report the client's allergy to shrimp due to a potential

allergic reaction to the contrast dye

E - Incorrect: There is no contraindication related to contrast dye for a client who has an

allergy to latex.

A nurse is collecting data from a client who was admitted to the medical-surgical unit 12 hr ago after falling off a ladder and hitting his head. The client is drowsy, but responds to verbal commands, and opens his eyes when the nurse calls his name. He is oriented to time, place, and person. The nurse should document the client's motor Glasgow Coma Scale score as which of the following?

A. 6

B. 5

C. 4

D. 3

Answer:

A - The client's motor score is 6 beacsue he able to follow commands. If the client only

responds to local pain, his score is 5. If the client has a general withdrawal to pain, his score

is 4. If the client assumes a decorticate posture, his score is 3.


A nurse is caring for a client post-lumbar puncture who reports a throbbing headache when sitting upright for meals. Which of the following actions should the nurse take? (SELECT ALL THAT APPLY)

A. Use the Glasgow Coma Scale when checking the client.

B. Assist the client to eat meals while lying flat in bed

C. Administer an opiod medication

D. Encourage the client to increase fluid intake

E. Place the client in a "cannonball" position.

Answer:

A - Incorrect: The nurse should use the Glasgow Coma Scale to determine a client's level of

consciousness

B - CORRECT: The prone position may relieve a headache following a lumbar puncture

C - CORRECT: Administering an opioid medication for a client's report of headache pain is

an appropriate action by the nurse.

D - CORRECT: Maintaining positive fluid balance may relieve a headache following a lumbar

puncture

E - Incorrect: The cannonball position is appropriate for the client undergoing the procedure

of lunbar puncture, but it is not used to relieve a client's headache following the procedure

seizures practice test key

Documents

clients seizure

seizure activity

type of seizure

minute seizure

nurse implement

incorrect assessment

important action

correct accurate assessment