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A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.)
- A. Lip smacking
- B. Sudden loss of muscle tone
- C. Brief jerking of the extremities
- D. Picking at clothing
- E. Staring spell
Correct Answer: A,D,E
Rationale: Absence seizures are characterized by brief lapses in attention, often with staring spells, lip smacking, or picking at clothing. Sudden loss of muscle tone is more typical of atonic seizures, and brief jerking of extremities is associated with myoclonic seizures.
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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 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 is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.)
- A. Sodium levels
- B. Clotting factors
- C. White blood cell count
- D. C-reactive protein
- E. Liver enzymes
Correct Answer: A,B
Rationale: Inflammation from meningitis can stimulate the hypothalamus, leading to excessive antidiuretic hormone production, causing syndrome of inappropriate antidiuretic hormone (SIADH); thus, sodium levels should be monitored. Systemic inflammatory response syndrome (SIRS) can lead to coagulopathy and disseminated intravascular coagulation, requiring monitoring of clotting factors. Other values are not specific to meningitis complications.
A nurse is teaching the daughter of a client who has Alzheimers disease. The daughter asks, Will the medication my mother is taking improve her dementia? How should the nurse respond?
- A. It will allow your mother to live independently for several more years.
- B. It is used to halt the advancement of Alzheimers disease but will not cure it.
- C. It will not improve her dementia but can help control emotional responses.
- D. It will cure the dementia but not improve memory.
Correct Answer: C
Rationale: Medications for Alzheimer's disease, such as cholinesterase inhibitors, do not improve dementia or halt its progression but can help manage symptoms, including emotional responses. The other options are incorrect as they overstate the medication's effects or are not accurate.
A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which a nurse should the nurse needs in this clients teaching?
- A. Take this drug only when you have prodforma symptoms indicating the onset of a migraine headache.
- B. Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches.
- C. This drug will relieve the pain during the arm phase soon after a headache has started.
- D. This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines.
Correct Answer: B
Rationale: Beta blockers are prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client should monitor these side effects. The other responses do not discuss appropriate uses of the medication.
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.