Nokea
A nurse is assessing a client's seizure activity. Which of the following would the nurse include? Select all that apply.
- A. Description of seizures
- B. Seizure frequency
- C. Average length of seizures
- D. Description of aura
- E. Description of the degree of impairment
Correct Answer: A,B,C,D,E
Rationale: The nurse's general assessment of seizure activity should include the following: description of seizures, seizure frequency, average length of seizures, description of aura, description of the degree of impairment, and description of what appears to bring on the seizure.
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The primary health care provider prescribes diazepam 10 mg IV to be administered to a client to control his seizures. The nurse would administer this drug over which time frame?
- A. 1 minute
- B. 2 minutes
- C. 5 minutes
- D. 10 minutes
Correct Answer: B
Rationale: When used to control seizures, diazepam is administered IV pushed slowly as close as possible to the IV site, allowing at least 1 minute for each 5 mg of drug. For a dosage of 10 mg, the nurse would administer the drug over 2 minutes.
A client comes to the clinic for a follow-up visit. The client is prescribed lamotrigine for seizure control. The nurse suspects that the client may be experiencing Stevens-Johnson syndrome based on which of the following?
- A. Complaints of muscle pain
- B. Lesions on the mucous membranes
- C. Blisters on the face and neck
- D. Recurrence of seizure activity
- E. Dizziness
Correct Answer: A,B,C
Rationale: Stevens-Johnson syndrome (SJS) is manifested by fever, cough, muscular aches and pains, headache, and lesions of the skin, mucous membranes, and eyes; the lesions appear as red wheals or blisters, often starting on the face, in the mouth, or on the lips, neck, and extremities. Recurrence of seizure activity and dizziness are not associated with this condition.
A nurse is preparing to administer phenytoin to a client. The nurse understands the need to administer this drug cautiously if the client has a history of which of the following? Select all that apply.
- A. Hyperthyroidism
- B. Hypotension
- C. Diabetes
- D. Asthma
- E. Hepatic impairment
Correct Answer: B,E
Rationale: Phenytoin (Dilantin) is used cautiously in clients with hypotension, severe myocardial insufficiency, and hepatic impairment.
Assessment of a client receiving anticonvulsant therapy reveals the following: sore throat, chills, fever, gingival bleeding, and bruising. Which nursing diagnosis would the nurse most likely identify?
- A. Risk for Impaired Skin Integrity
- B. Impaired Oral Mucous Membranes
- C. Risk for Injury
- D. Risk for Infection
Correct Answer: D
Rationale: The assessment findings suggest pancytopenia, so Risk for Infection would be most likely. Risk for Impaired Skin Integrity would be appropriate if the client developed a rash. Impaired Oral Mucous Membranes would be appropriate if the client was exhibiting signs of gingival hyperplasia. Risk for Injury would be appropriate if the client was experiencing drowsiness, ataxia, and vision disturbances related to the drug therapy.
The nurse is assessing a client who is receiving felbamate. The nurse suspects that the client may be developing pancytopenia based on which assessment finding? Select all that apply.
- A. Gingival hyperplasia
- B. Sore throat
- C. Epistaxis
- D. Skin rash
- E. Bruising
Correct Answer: B,C,E
Rationale: Signs of pancytopenia include sore throat, fever, general malaise, bleeding of the mucous membranes, epistaxis (bleeding from the nose), and easy bruising. Gingival hyperplasia and skin rash are examples of adverse reactions, but these are not associated with pancytopenia.