Nokea
The school nurse notes a 6-year-old running across the playground with friends. The child stops in midstride, freezing for a few seconds. Then the child resumes running across the playground. The school nurse suspects what in this child?
- A. An absence seizure
- B. A myoclonic seizure
- C. A partial seizure
- D. A tonic-clonic seizure
Correct Answer: A
Rationale: Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. Both myoclonic and tonic-clonic seizures involve jerking movements.
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The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased intracranial pressure (ICP). What neurologic sequelae might this client develop?
- A. Damage to the nerves that facilitate vision and hearing
- B. Damage to the vagal nerve
- C. Damage to the olfactory nerve
- D. Damage to the facial nerve
Correct Answer: A
Rationale: Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve, or the facial nerve.
A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse?
- A. Insert an airway or bite block.
- B. Manually restrain the extremities.
- C. Turn client to side-lying position.
- D. Monitor vital signs.
Correct Answer: C
Rationale: When a client begins to convulse, the highest priority is to maintain airway. This can best be accomplished by turning client to side-lying position, which allows saliva and emesis to drain from the mouth. Turning the client also allows the tongue to fall forward opening the airway. More damage can occur if a bite block is inserted after the seizure has begun. Manually restraining extremities is not recommended. Attempting to take blood pressure is not recommended and pulse rate and respirations during the event will not be beneficial. Monitor vital signs during the postictal phase.
The nurse is caring for a client who has a generalized seizure. Which nursing assessment is a priority for detailing the event?
- A. Seizure began at 1300 hours.
- B. The client cried out before the seizure began.
- C. Seizure was 1 minute in duration including tonic-clonic activity.
- D. Sleeping quietly after the seizure
Correct Answer: C
Rationale: Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and the skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.
The nurse is caring for a 30-year-old client diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse?
- A. I will have progressive muscle weakness.
- B. I will lose strength in my arms.
- C. My children are at greater risk to develop this disease.
- D. I need to remain active for as long as possible.
Correct Answer: C
Rationale: There is no known cause for ALS, and no reason to suspect genetic inheritance. ALS usually begins with muscle weakness of the arms and progresses. The client is encouraged to remain active for as long as possible to prevent respiratory complications.
The nurse is caring for a client newly diagnosed with Parkinson disease. Which topic is most important for the nurse to include in the teaching plan for this client?
- A. Involvement with diversion activities
- B. Enhancement of the immune system
- C. Establishing balanced nutrition
- D. Maintaining a safe environment
Correct Answer: D
Rationale: The primary focus in caring for Parkinson disease is on maintaining a safe environment. Parkinson disease often has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking and an inability to stop abruptly without losing balance. Prevention of communicable diseases and establishing a balanced nutrition is encouraged with any chronic disorder. Diversional activities can be helpful in times of stress but not a priority.