The Client with Seizures and CVA

1. Which of the following is contraindicated for a client with seizure precautions?1.   Encouraging him to perform his own personal hygiene.2.   Allowing him to wear his own clothing.3.   Assessing oral temperature with a glass thermometer.4.   Encouraging him to be out of bed.

Temperatures are not assessed orally with a glass thermometer because the thermometer could break and cause injury if a seizure occurred. The client can perform personal hygiene. There is no clinical reason to discourage the client from wearing his own clothes. As long as there are no other limitations, the client should be encouraged to be out of bed.

2. A client who is unconscious from an unknown drug overdose is having grand mal seizures. Which of the following would the nurse expect to administer? Select all that apply.

1.   Dextrose 50%, 50 mL IV bolus.2.   Flumazenil, 0.2 mg IV.3.   Thiamine, 100 mg IV4.   Naloxone, 0.45 mg IV.

Severe hypoglycemia causing irreversible brain damage can occur quickly in a client who is unconscious and experiencing a seizure. Therefore, unless a rapid blood glucose level is available to rule out hypoglycemia, the nurse would expect to administer a bolus of Dextran 50% 50 to 100 mL IV. Thiamine is administered to clients who are malnourished or abuse alcohol and would not be contraindicated in this client. Naloxone is administered to clients suspected of a narcotic drug or opioid overdose to reverse comas or narcotic-induced respiratory depression and is an appropriate order for this client. Flumazenil is administered to reverse benzodiazepine overdose but it should not be given with a seizure disorder.

3. Which of the following will the nurse observe in the client in the ictal phase of a generalized grand mal (tonic-clonic) seizure?

1.   Jerking in one extremity that spreads gradually to adjacent areas.2.   Vacant staring and an abrupt cessation of all activity.3.   Facial grimaces, patting motions, and lip smacking.4.   Loss of consciousness, body stiffening, and violent muscle contractions.

A grand mal seizure involves both a tonic phase and a clonic phase. The tonic phase consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction, which lasts about 20 to 30 seconds. The clonic phase involves repetitive movements. The grand mal seizure ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts in one region of the cortex and may stay focused or spread (eg, jerking in the extremity spreading to other areas of the body). A petit mal seizure usually occurs in children and involves a vacant stare with a brief loss of consciousness that often goes unnoticed. A complex partial seizure involves facial grimacing with patting and smacking.

4. It is the night before a client is to have a computed tomographic (CT) scan of the head without contrast. Which statement by the nurse would be most appropriate?

1.   "You must shampoo your hair tonight to remove all oil and dirt."2.   "You may drink fluids until midnight; but after that drink nothing until the scan is

completed."3.   "You will have some hair shaved to attach the small electrode to your scalp."4.   "You will need to hold your head very still during the examination."

The client will be asked to hold the head very still during the examination, which lasts about 30 to 60 minutes. In some instances, food and fluids may be withheld for 4 to 6 hours before the procedure if a contrast medium is used, because the radiopaque substance sometimes causes nausea. There is no special preparation for a CT scan, so a shampoo the night before is not required. The client may drink fluids until 4 hours before the scan is scheduled. Electrodes are not used for a CT scan, nor is the head shaved.

5. For breakfast on the morning a client is to have an electroencephalogram (EEG), the client is served a soft-boiled egg, toast with butter and marmalade, orange juice, and coffee. Which of the following would the nurse do?

1.   Remove all the food.2.   Remove the coffee.3.   Remove the toast, butter, and marmalade only.4.   Substitute vegetable juice for the orange juice.

Beverages containing caffeine, such as coffee, tea, and cola drinks, are withheld before an EEG because of the stimulating effects of the caffeine on the brain waves. A meal should not be omitted before an EEG, because low blood sugar could alter brain wave patterns.

6. Upon awakening from his first tonic-clonic seizure, a 20-year-old client asks the nurse, "What caused me to have a seizure? I've never had one before." Which of the following would the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than 20 years?

1.   Head trauma.2.   Electrolyte imbalance.3.   Congenital defect.4.   Epilepsy.

Trauma is one of the primary causes of brain damage and seizure activity in adults. Other common causes of seizure activity in adults include neoplasms, withdrawal from drugs and alcohol, and vascular disease.

7. Which of the following would the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin (Neurontin)?

1.   Take all the medication until it is gone.2.   Notify the physician if vision changes occur.3.   Store gabapentin in the refrigerator.4.   Take gabapentin with an antacid to protect against ulcers.

Gabapentin may impair vision. Changes in vision, concentration, or coordination should be reported to the physician. Gabapentin should not be stopped abruptly because of the potential for status epilepticus; this is a medication that must be tapered off. Gabapentin

is to be stored at room temperature and out of direct light. It should not be taken with antacids.

8. What is the priority nursing intervention in the postictal phase of a seizure?1.   Reorient the client to time, person, and place.2.   Determine the client's level of sleepiness.3.   Assess the client's breathing pattern.4.   Position the client comfortably.

A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client's level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent.

9. Which intervention is most effective in minimizing the risk of seizure activity in a client who is undergoing diagnostic studies after having experienced several episodes of seizures?

1.   Maintain the client on bed rest2.   Administer butabarbital sodium (phenobarbital) 30 mg orally, three times per day.3.   Close the door to the room to minimize stimulation.4.   Administer carbamazepine (Tegretol) 200 mg orally, twice per day.

Carbamazepine (Tegretol) is an anticonvulsant that helps prevent further seizures. Bed rest, sedation (phenobarbital), and providing privacy do not minimize the risk of seizures

10.What nursing assessments should be documented at the beginning of the ictal phase of a seizure?

1.   Heart rate, respirations, pulse oximeter, and blood pressure2.   Last dose of anticonvulsant and circumstances at the time.3.   Type of visual, auditory, and olfactory aura the client experienced.4.   Movement of the head and eyes and muscle rigidity.

During a seizure, the nurse should note movement of the client's head, eyes, and muscle rigidity, especially when the seizure first begins, to obtain clues about the location of the trigger focus in the brain. Other important assessments would include noting the progression and duration of the seizure, respiratory status, loss of consciousness, pupil size, and incontinence of urine and stool. It is typically not possible to assess the client's pulse and blood pressure during a tonic-clonic seizure because the muscle contractions make assessment difficult to impossible. The last dose of anticonvulsant medication can be evaluated later. The nurse should focus on maintaining an open airway, preventing injury to the client, and assessing the onset and progression of the seizure to determine the type of brain activity involved. The type of aura should be assessed in the preictal phase of the seizure

11.Which clinical manifestation does the nurse expect in the client in the postictal phase of grand mal seizure?

1.   Drowsiness.2.   Inability to move.3.   Paresthesia.

4.   Hypotension.

The nurse would expect a client to experience drowsiness to somnolence in the postictal phase, because exhaustion results from the abnormal spontaneous neuron firing and tonic-clonic motor response. An inability to move a muscle part is not expected after a tonic-clonic or grand mal seizure, because a lack of motor function would be related to a complication such as a lesion, tumor, or cerebrovascular accident in the correlating brain tissue. A change in sensation would not be expected, because this would indicate a complication such as an injury to the peripheral nerve pathway to the corresponding part from the central nervous system. Hypotension is not typically a problem after a seizure.

12.A client with seizures asks the nurse how phenytoin sodium (Dilantin) will help. Based on knowledge of the drug's action, what is the nurse's best response?

1.   It corrects the abnormal synthesis of norepinephrine in the body.2.   Transmission of abnormal impulses in the spinal cord is depressed.3.   The responsiveness of neurons in the brain to abnormal impulses is reduced.4.   It interrupts the flow of abnormal impulses from peripheral neurons in the viscera to

the brain.

Exactly how phenytoin sodium helps control seizures is unclear. The most common theory is that it reduces the responsiveness of neurons in the brain to abnormal impulses—that is, it depresses neural activity. Dilantin does not influence norepinephrine or transmission of impulses in the spinal cord, nor does it interrupt the flow of abnormal impulses from peripheral neurons in the viscera to the brain.

13.When preparing to teach a client about phenytoin sodium (Dilantin) therapy, the nurse would urge the client not to stop the drug suddenly because

1.   physical dependency on the drug develops over time.2.   status epilepticus may develop.3.   a hypoglycemic reaction develops.4.   heart block is likely to develop.

Anticonvulsant drug therapy should never be stopped suddenly; doing so can lead to the life-threatening status epilepticus. Phenytoin sodium does not carry a risk of physical dependency or lead to hypoglycemia. Phenytoin sodium has antiarrhythmic properties, and discontinuation does not cause heart block.

14.client states that she is afraid she will not be able to drive again because of her seizures. Which response by the nurse would be best?

1.   A person with a history of seizures can drive only during daytime hours.2.   A person with evidence that the seizures are under medical control can drive.3.   A person with evidence that seizures occur no more often than every 12 months

can drive.4.   A person with a history of seizures can drive if he carries a medical identification

card.

Specific motor vehicle regulations and restrictions for people who experience seizures vary locally. Most commonly, evidence that the seizures are under medical control is required before the person is given permission to drive. Time of day is not a consideration when determining driving restrictions related to seizures. The amount of time a person has been seizure free is a consideration for lifting driving restrictions;

however, the time frame is usually 2 years. It is recommended, not required, that a person who is subject to seizures carry a card or wear an identification bracelet describing the illness to facilitate quick identification in the event of an emergency.

15.A client tells the nurse that he is unclear about what an aura is. The nurse's response indicates that an aura is

1.   a postictal state of amnesia.2.   an hallucination that occurs during a seizure.3.   a symptom that occurs just before a seizure.4.   a feeling of relaxation as the seizure begins to subside.

An aura is a premonition of an impending seizure. Auras usually are of a sensory nature (ie, an olfactory, visual, gustatory, or auditory sensation); some may be of a psychic nature. Evaluating an aura may help identify the area of the brain from which the seizure originates.

16.Which statement by a client with a seizure disorder taking topiramate (Topamax) indicates the client has understood the nurse's instruction?

1.   "I will take the medicine before going to bed."2.   "I will drink 6 to 8 glasses of water a day."3.   "I will eat plenty of fresh fruits."4.   "I will take the medicine with a meal or snack."

Toxic effects of topiramate are nephrolithiasis, and clients are encouraged to drink 6 to 8 glasses of water a day to dilute the urine and flush the renal tubules to avoid stone formation. Topamax is taken in divided doses because it produces drowsiness. Although eating fresh fruits is desirable from a nutritional standpoint, this is not related to the topiramate. The drug does not have to be taken with meals.

17.Which clinical manifestation does the nurse assess as a typical reaction to long-term phenytoin sodium (Dilantin) therapy?

1.   Weight gain2.   Insomnia.3.   Excessive growth of gum tissue.4.   Deteriorating eyesight.

A common side effect of long-term phenytoin therapy is an overgrowth of gingival tissues. Problems may be minimized with good oral hygiene, but in some cases, overgrown tissues must be removed surgically.

18.Regular oral hygiene is an essential intervention for the client who has had a cerebrovascular accident (CVA). Which of the following nursing measures is inappropriate when providing oral hygiene?

1.   Placing the client on the back with a small pillow under the head.2.   Keeping portable suctioning equipment at the bedside.3.   Opening the client's mouth with a padded tongue blade.4.   Cleaning the client's mouth and teeth with a toothbrush.

A helpless client should be positioned on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration.

19.A client arrives in the emergency department with an ischemic CVA and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment?

1.   Current medications.2.   Complete physical and history.3.   Time of onset of current CVA.4.   Upcoming surgical procedures.

Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a CVA have better outcomes. The time from the onset of stroke to t-PA treatment is a priority assessment. A complete physical and history is not possible when a client is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of t-PA administration, which is a priority in the immediate treatment of the current CVA.

20.During the first 24 hours after thrombolytic treatment for an ischemic CVA, the primary goal is to control the client's

1.   pulse.2.   respirations.3.   blood pressure.4.   temperature.

Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major side effect of thrombolytic therapy. Vital signs are monitored, and the blood pressure is maintained as identified by the physician and specific to the client's ischemic tissue needs and risk of bleeding from treatment.

21.What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic CVA?

1.   Cholesterol level.2.   Pupil size and pupillary response.3.   Bowel sounds.4.   Echocardiogram.

It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, although it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hours, when the primary concerns are cerebral hemorrhage and increased intracranial pressure. An echocardiogram is not needed for the client with a thrombotic CVA without heart problems.

22.What is a priority nursing intervention when suctioning an unconscious client to maintain cerebral perfusion?

1.   Hyperoxygenate before and after suctioning.2.   Administer analgesics3.   Provide oral hygiene.4.   Administer diuretics.

It is a priority to hyperoxygenate the client before and after suctioning to prevent hypoxia and to maintain cerebral perfusion. Analgesics are administered to provide pain relief.

Oral hygiene provides asepsis and comfort. Diuretics assist in reducing the intracranial pressure.

23.The nursing assessment of a client's functional status before and after a CVA is essential. Why is it so important?

1.   The rehabilitation plan will be guided by it.2.   Functional status before the CVA will help predict outcomes.3.   It will help the client recognize his physical limitations.4.   The client can be expected to regain much of his functioning.

The primary reason for the nursing assessment of a client's functional status before and after a CVA is to guide the plan. The assessment does not help to predict how far the rehabilitation team can help the client to recover from the residual effects of the CVA, only what plans can help a client who has moved from one functional level to another. The nursing assessment of the client's functional status is not a motivating factor.

24.Which of the following techniques does the nurse avoid when changing a client's position in bed if the client has hemiparalysis?

1.   Rolling the client onto her side.2.   Sliding the client to move her up in bed.3.   Lifting the client when moving her up in bed4.   Having the client help lift herself off the bed using a trapeze.

Sliding a client on a sheet causes friction and is to be avoided. Friction injures skin and predisposes to pressure ulcer formation. Rolling the client is an acceptable method to use when changing positions as long as the client is maintained in anatomically neutral positions and her limbs are properly supported. The client may be lifted as long as the nurse has assistance and uses proper body mechanics to avoid injury to himself or herself or the client. Having the client help lift herself off the bed with a trapeze is an acceptable means to move a client without causing friction burns or skin breakdown.

25.Which nursing intervention has been found to be the most effective means of preventing plantar flexion in a client who has had a CVA with residual paralysis?

1.   Place the client's feet against a firm footboard.2.   Reposition the client every 2 hours.3.   Have the client wear ankle-high tennis shoes at intervals throughout the day.4.   Massage the client's feet and ankles regularly.

The use of ankle-high tennis shoes has been found to be most effective in preventing plantar flexion (foot drop) because they add support to the foot and keep it in the correct anatomic position. Footboards stimulate spasms and are not routinely recommended. Regular repositioning and range-of-motion exercises are important interventions, but the client's foot needs to be left in correct anatomic position to prevent overextension of the muscle and tendon of the foot.

26.The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm. What position would be inappropriate?

1.   Placing a pillow in the axilla so that the arm is away from the body.2.   Placing a pillow under the slightly flexed arm so that the hand is higher than the

elbow.3.   Positioning the hands in a slightly pronated position.

4.   Positioning a roll in the hand so that the fingers are barely flexed.

When voluntary muscle control is lost, the flexor muscles, which are stronger, exert control over the extensor muscles. Folding the arms over the chest allows the flexor muscles to flex and exert control over the already weaker extensor muscles. It is better to extend the arms of the client to allow the extensor muscles to exert control over the flexor muscles and prevent contractures. Placing a pillow in the axilla so that the arm is away from the body keeps the arm abducted and prevents skin from touching skin, which leads to skin breakdown. Placing a pillow under the slightly flexed arm so that the hand is higher than the elbow prevents edema. Positioning a roll in the hand so that the fingers are barely flexed prevents the flexor muscles from overtaking the extensors.

27.For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?

1.   Speaking loudly.2.   Using a picture board.3.   Writing directions so client can read them.4.   Speaking in short sentences.

Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires

28.The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is inappropriate?

1.   Maintaining an upright position.2.   Restricting the diet to liquids until swallowing improves.3.   Introducing foods on the unaffected side of the mouth.4.   Keeping distractions to a minimum.

A client with dysphagia (difficulty swallowing) frequently has the most difficulty ingesting thin liquids, which are easily aspirated. Liquids should be thickened to avoid aspiration. Maintaining an upright position while eating is appropriate because it minimizes the risk of aspiration. Introducing foods on the unaffected side allows the client to have better control over the food bolus. The client should concentrate on chewing and swallowing; therefore, distractions should be avoided.

29.Which food-related behaviors would the nurse observe in a client who has had a CVA that has left him with homonymous hemianopia?

1.   Increased preference for foods high in salt.2.   Eating food on only half of the plate.3.   Forgetting the names of foods.4.   Inability to swallow liquids.

Homonymous hemianopia is blindness in half of the visual field; therefore, the client would see only half of his plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships. There may be an increased preference for foods high in salt after a CVA, but this would not be related to homonymous hemianopia. Forgetting the names of foods would be aphasia, which

involves a cerebral cortex lesion. Being unable to swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX and X, including the lower brain stem.

30.The nurse is teaching the client about ways to adapt to a visual disability. Which does the nurse identify as the primary safety precaution to use?

1.   Wear a patch over one eye.2.   Place personal items on the sighted side.3.   Lie in bed with the unaffected side toward the door.4.   Turn the head from side to side when walking.

To expand the visual field, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight.

31.A client is experiencing mood swings after a CVA and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode?

1.   Sit quietly with the client until the episode is over.2.   Ignore the behavior.3.   Attempt to divert the client's attention.4.   Tell the client that this behavior is unacceptable.

A client who has brain damage may be emotionally labile and may cry or laugh for no explainable reason. Crying episodes are best dealt with by attempting to divert the client's attention. Ignoring the behavior will not affect the mood swing or the crying and may increase the client's sense of isolation. Telling the client to stop is inappropriate.

32.The client who has had a CVA with residual physical handicaps becomes discouraged by his physical appearance. What attitude is best for the nurse to display to help the client overcome his negative self-concept?

1.   Helpfulness and sympathy.2.   Concern and charity.3.   Directives and firmness.4.   Encouragement and patience.

When offering emotional support to a client who is discouraged and has a negative self-concept because of physical handicaps, the nurse should display encouragement and patience. The client should be praised when he shows progress in his efforts to overcome handicaps. An attitude of helpfulness and sympathy allows the client to assume a role of someone not ordinary, someone who is not like others. Regardless of the handicap, the client still feels the same on the inside and has the same innate needs for his growth and developmental age group. An attitude of concern and charity tends to make the client feel like a "charity case" or like someone who is given something free because of his "condition." The client feels unequal to his peers or unable to fulfill the role relationships that were obtained before the CVA. An attitude of directives and firmness is inappropriate because it implies that the client can do better if he just tries harder and leaves no room for softness in the approach to overcoming a negative self-concept.

33.When communicating with a client who has aphasia, which of the following nursing interventions is inappropriate?

1.   Present one thought at a time.2.   Encourage the client not to write messages.3.   Speak with normal volume.4.   Make use of gestures.

The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to "show me" and should encourage the use of gestures to assist in getting the message across with minimal frustration and exhaustion for the client.

34.What is the expected outcome of thrombolytic drug therapy for CVA?1.   Increased vascular permeability.2.   Vasoconstriction.3.   Dissolved emboli.4.   Prevention of hemorrhage.

Thrombolytic enzyme agents are used for clients with a thrombotic CVA to dissolve emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.