Silvestri, 3/e, ISBN 1-1460-0052-6Chapter 030 (edited file)—"Neurological, Cognitive, and Psychosocial Disorders"10/14/08, Page 3 of 9, 2 Figure(s), 0 Table(s), 4 Box(es)
References: Leifer, G. (2003).
Introduction to maternity and pediatric nursing
(4th ed.).Philadelphia: W.B. Saunders, p. 545.Price, D., & Gwin, J. (2005).
Thompson’s pediatric nursing
(9th ed.). Philadelphia: W.B.Saunders, p. 304.5. Which of the following, if noted by the nurse, would indicate a potential complicationassociated with a tonic-clonic seizure?1. Blood on the pillow2. Blanched toenails3. Migraine headaches4. High-pitched cryAnswer: 1Rationale: The complications associated with seizures include airway compromise, extremityand teeth injuries, and tongue lacerations. Night seizures can cause the child to bite down on thetongue. Cyanosis can occur during the tonic-clonic part of the seizure activity, but blanchingdoes not occur. Migraine headaches are not common in children with seizures. Seizures do notcause a high-pitched cry, unless a tumor or intracranial pressure is the cause of the seizurediagnosis.Test-Taking Strategy: Use knowledge of tonic-clonic activity and the involuntary tightening of all the body muscles that occurs during seizure activity when answering this question. Recallthat the tongue can get easily caught by the child’s teeth when the seizure activity occurs. Thiscauses injury, swelling, and bleeding of the tongue tissue. Review the complications associatedwith seizures if you had difficulty with this question.Level of Cognitive Ability: ComprehensionClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/Data CollectionContent Area: Child HealthReference: Price, D., & Gwin, J. (2005).
Thompson’s pediatric nursing
(9th ed.). Philadelphia:W.B. Saunders, p. 241.6. A nurse plans for a safe environment when caring for an infant at risk for a seizure. In the plan of care, the seizure precautions would include placing which of the following items at the bedside?1. A suction apparatus and an airway2. Oxygen with a tracheotomy set3. Emergency cart4. Airway and a tracheotomy setAnswer: 1Rationale: Seizures cause tightening of all body muscles followed by tremors. Obstructiveairway and increased oral secretions are the major complications during and following theseizure. Option 2 and 4 are incorrect because inserting a tracheostomy is not done. Suctioning ishelpful to prevent choking and cyanosis. Option 3 is incorrect, because this cart would not beleft at the bedside, but would be available in the treatment room or on the nursing unit.Test-Taking Strategy: Use the process of elimination. Recalling that seizures produce excessiveoral secretions and airway obstruction will direct you to option 1. Review the plan of careassociated with seizure precautions if you had difficulty with this question.