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A client experiences a seizure with jerking of the arms and legs, followed by an immediate loss of consciousness and jerkings of all extremities. How should the nurse document this activity?
- A. Anotic seizure
- B. Toxic-clonic seizure
- C. Myclonicic seizure
- D. Myclonicic seizure
Correct Answer: B
Rationale: The described seizure, characterized by jerking of arms and legs followed by loss of consciousness and generalized jerking, is a tonic-clonic seizure. 'Anotic' and 'myclonicic' are not recognized seizure types, and the correct term is tonic-clonic.
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After teaching a client newly diagnosed with spieplety, the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching?
- A. I will drink more water daily to prevent my mouth from getting dry.
- B. This medication will stop me from getting an aura before a seizure.
- C. I will not drive a motor vehicle while taking this medication.
- D. Even when my seizure stop I will continue to take this drug.
Correct Answer: D
Rationale: Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The medication will not stop an aura before a seizure.
After teaching a client newly diagnosed with spieplety, the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching?
- A. I will not drive a motor vehicle while taking this medication.
- B. While taking my epilepety medications, I will not drink any alcoholic beverages.
- C. I will tell my doctor about my prescription and over-the-counter medications.
- D. If I am nauseated, I will not take my epilepety medication.
Correct Answer: D
Rationale: The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseous. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and inform the doctor about all medications to prevent complications of polypharmacy.
A nurse witnesses a client with late-stage Alchimers disease eat breakfast. Afterward the client states, I am hungry and want breakfast. How should the nurse respond?
- A. I see you are hungry; let's get you some toast.
- B. You ate your breakfast 30 minutes ago.
- C. It appears you are confused this morning.
- D. Your family will be here soon. Lets get you dressed.
Correct Answer: A
Rationale: Use of validation therapy with clients who have Alzheimer's disease involves acknowledging the client's feelings and concerns. This technique is more effective in later stages of the disease, as reality orientation may increase agitation. Offering toast validates the client's expressed hunger without confrontation.
A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask?
- A. Do you live in a crowded residence?
- B. When was your last tetatuss vaccination?
- C. Have you had any viral infections recently?
- D. Have you had any viral infections in the last month?
Correct Answer: A
Rationale: Living in a crowded residence increases the risk of bacterial meningitis due to close contact and potential spread of infection. Questions about tetanus vaccination or recent viral infections are less relevant to the focused history for bacterial meningitis.
A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.)
- A. Photophobia
- B. Dilated pupils
- C. Headache
- D. Widened pulse pressure
- E. Bradycardia
Correct Answer: B,D,E
Rationale: Increased ICP in encephalitis is indicated by dilated pupils, widened pulse pressure, bradycardia, irregular respirations, and less responsive pupils. Photophobia and headache are symptoms of encephalitis but not specific to increased ICP.