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The Client with Seizures and CVA

1. Which of the following is contraindicated for a client with seizure precautions? 1. Encouraging him to perform his own personal hygiene. 2. Allowing him to wear his own clothing. 3. Assessing oral temperature with a glass thermometer. 4. Encouraging him to be out of bed. Temperatures are not assessed orally with a glass thermometer because the thermometer could break and cause injury if a seizure occurred. The client can perform personal hygiene. There is no clinical reason to discourage the client from wearing his own clothes. As long as there are no other limitations, the client should be encouraged to be out of bed. 2. A client who is unconscious from an unknown drug overdose is having grand mal seizures. Which of the following would the nurse expect to administer? Select all that apply. 1. Dextrose 50%, 50 mL IV bolus. 2. Flumazenil, 0.2 mg IV. 3. Thiamine, 100 mg IV 4. Naloxone, 0.45 mg IV. Severe hypoglycemia causing irreversible brain damage can occur quickly in a client who is unconscious and experiencing a seizure. Therefore, unless a rapid blood glucose level is available to rule out hypoglycemia, the nurse would expect to administer a bolus of Dextran 50% 50 to 100 mL IV. Thiamine is administered to clients who are malnourished or abuse alcohol and would not be contraindicated in this client. Naloxone is administered to clients suspected of a narcotic drug or opioid overdose to reverse comas or narcotic-induced respiratory depression and is an appropriate order for this client. Flumazenil is administered to reverse benzodiazepine overdose but it should not be given with a seizure disorder. 3. Which of the following will the nurse observe in the client in the ictal phase of a generalized grand mal (tonic-clonic) seizure? 1. Jerking in one extremity that spreads gradually to adjacent areas. 2. Vacant staring and an abrupt cessation of all activity. 3. Facial grimaces, patting motions, and lip smacking. 4. Loss of consciousness, body stiffening, and violent muscle contractions. A grand mal seizure involves both a tonic phase and a clonic phase. The tonic phase consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction, which lasts about 20 to 30 seconds. The clonic phase involves repetitive movements. The grand mal seizure ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts in one region of the cortex and may stay focused or spread (eg, jerking in the extremity spreading to other areas of the body). A petit mal seizure usually occurs in children and involves a vacant stare with a brief loss of consciousness that often goes unnoticed. A complex partial seizure involves facial grimacing with patting and smacking. 4. It is the night before a client is to have a computed tomographic (CT) scan of the head without contrast. Which statement by the nurse would be most appropriate?

3. orange juice. 7. Electrodes are not used for a CT scan. nor is the head shaved. such as coffee. 2. the client is served a soft-boiled egg. 4. and cola drinks. Store gabapentin in the refrigerator. because the radiopaque substance sometimes causes nausea." The client will be asked to hold the head very still during the examination. 4. In some instances." 4. but after that drink nothing until the scan is completed. or coordination should be reported to the physician." 3. which lasts about 30 to 60 minutes. For breakfast on the morning a client is to have an electroencephalogram (EEG). Gabapentin should not be stopped abruptly because of the potential for status epilepticus. The client may drink fluids until 4 hours before the scan is scheduled. Substitute vegetable juice for the orange juice. "You will have some hair shaved to attach the small electrode to your scalp." Which of the following would the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than 20 years? 1. Take all the medication until it is gone. Which of the following would the nurse do? 1. Epilepsy." "You may drink fluids until midnight. Gabapentin may impair vision. tea. Head trauma. 5. "What caused me to have a seizure? I've never had one before. food and fluids may be withheld for 4 to 6 hours before the procedure if a contrast medium is used. butter. 3. Take gabapentin with an antacid to protect against ulcers. Electrolyte imbalance. Remove all the food. so a shampoo the night before is not required. 2. and vascular disease. 4. because low blood sugar could alter brain wave patterns. 6. and coffee. Notify the physician if vision changes occur. Remove the coffee. this is a medication that must be tapered off. Beverages containing caffeine. Upon awakening from his first tonic-clonic seizure. 3. A meal should not be omitted before an EEG. Remove the toast. 2. "You must shampoo your hair tonight to remove all oil and dirt. "You will need to hold your head very still during the examination. Which of the following would the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin (Neurontin)? 1. a 20-year-old client asks the nurse. There is no special preparation for a CT scan. Trauma is one of the primary causes of brain damage and seizure activity in adults. 2. Gabapentin . Congenital defect. and marmalade only. toast with butter and marmalade.1. withdrawal from drugs and alcohol. concentration. Changes in vision. Other common causes of seizure activity in adults include neoplasms. are withheld before an EEG because of the stimulating effects of the caffeine on the brain waves.

The last dose of anticonvulsant medication can be evaluated later. respiratory status. 2. sedation (phenobarbital). include reorientation of the client to time. Heart rate. It is typically not possible to assess the client's pulse and blood pressure during a tonic-clonic seizure because the muscle contractions make assessment difficult to impossible. Determining the client's level of sleepiness is useful. 8. Bed rest. person. The nurse should focus on maintaining an open airway. pulse oximeter. Inability to move. Assess the client's breathing pattern. Administer carbamazepine (Tegretol) 200 mg orally. eyes. and olfactory aura the client experienced. and providing privacy do not minimize the risk of seizures 10. person. Other interventions. 4. to be completed after the airway has been established. 3. It should not be taken with antacids. and place. 2. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent. Drowsiness. twice per day. respirations. Other important assessments would include noting the progression and duration of the seizure. The nurse should apply oxygen and ventilation to the client as appropriate. Which clinical manifestation does the nurse expect in the client in the postictal phase of grand mal seizure? 1. and assessing the onset and progression of the seizure to determine the type of brain activity involved. Which intervention is most effective in minimizing the risk of seizure activity in a client who is undergoing diagnostic studies after having experienced several episodes of seizures? 1. Position the client comfortably. Carbamazepine (Tegretol) is an anticonvulsant that helps prevent further seizures. Determine the client's level of sleepiness. 3. three times per day. but it is not a priority. 3. auditory. What nursing assessments should be documented at the beginning of the ictal phase of a seizure? 1. and muscle rigidity. 4. and depth. Administer butabarbital sodium (phenobarbital) 30 mg orally. Close the door to the room to minimize stimulation. Movement of the head and eyes and muscle rigidity. loss of consciousness. 9.is to be stored at room temperature and out of direct light. the nurse should note movement of the client's head. 3. Paresthesia. and incontinence of urine and stool. and place. What is the priority nursing intervention in the postictal phase of a seizure? 1. to obtain clues about the location of the trigger focus in the brain. especially when the seizure first begins. Type of visual. and blood pressure 2. Last dose of anticonvulsant and circumstances at the time. During a seizure. Maintain the client on bed rest 2. 4. rhythm. A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate. preventing injury to the client. The type of aura should be assessed in the preictal phase of the seizure 11. . pupil size. Reorient the client to time.

4. Hypotension is not typically a problem after a seizure. When preparing to teach a client about phenytoin sodium (Dilantin) therapy. 3. 2. Phenytoin sodium does not carry a risk of physical dependency or lead to hypoglycemia. A person with a history of seizures can drive if he carries a medical identification card. Which response by the nurse would be best? 1. Time of day is not a consideration when determining driving restrictions related to seizures. what is the nurse's best response? 1. or cerebrovascular accident in the correlating brain tissue. Transmission of abnormal impulses in the spinal cord is depressed. because this would indicate a complication such as an injury to the peripheral nerve pathway to the corresponding part from the central nervous system. The responsiveness of neurons in the brain to abnormal impulses is reduced. A person with evidence that the seizures are under medical control can drive. nor does it interrupt the flow of abnormal impulses from peripheral neurons in the viscera to the brain. and discontinuation does not cause heart block. Phenytoin sodium has antiarrhythmic properties. 2. Hypotension. the nurse would urge the client not to stop the drug suddenly because 1. Dilantin does not influence norepinephrine or transmission of impulses in the spinal cord. Specific motor vehicle regulations and restrictions for people who experience seizures vary locally. doing so can lead to the life-threatening status epilepticus. An inability to move a muscle part is not expected after a tonic-clonic or grand mal seizure. A person with a history of seizures can drive only during daytime hours. client states that she is afraid she will not be able to drive again because of her seizures.4. because a lack of motor function would be related to a complication such as a lesion. It corrects the abnormal synthesis of norepinephrine in the body. 4. Most commonly. The amount of time a person has been seizure free is a consideration for lifting driving restrictions. 2. A client with seizures asks the nurse how phenytoin sodium (Dilantin) will help. heart block is likely to develop. because exhaustion results from the abnormal spontaneous neuron firing and tonic-clonic motor response. It interrupts the flow of abnormal impulses from peripheral neurons in the viscera to the brain. evidence that the seizures are under medical control is required before the person is given permission to drive. Exactly how phenytoin sodium helps control seizures is unclear. it depresses neural activity. The most common theory is that it reduces the responsiveness of neurons in the brain to abnormal impulses —that is. A change in sensation would not be expected. Based on knowledge of the drug's action. a hypoglycemic reaction develops. 13. status epilepticus may develop. . 3. A person with evidence that seizures occur no more often than every 12 months can drive. 14. physical dependency on the drug develops over time. tumor. 3. 12. The nurse would expect a client to experience drowsiness to somnolence in the postictal phase. Anticonvulsant drug therapy should never be stopped suddenly. 4.

4. not on the back." 4. An aura is a premonition of an impending seizure. Auras usually are of a sensory nature (ie. Problems may be minimized with good oral hygiene. The nurse's response indicates that an aura is 1. "I will take the medicine with a meal or snack. 4. . 15." Toxic effects of topiramate are nephrolithiasis. Deteriorating eyesight. Cleaning the client's mouth and teeth with a toothbrush. Topamax is taken in divided doses because it produces drowsiness. a feeling of relaxation as the seizure begins to subside. 2. but in some cases. Which statement by a client with a seizure disorder taking topiramate (Topamax) indicates the client has understood the nurse's instruction? 1. an hallucination that occurs during a seizure. or auditory sensation). Insomnia. Placing the client on the back with a small pillow under the head. that a person who is subject to seizures carry a card or wear an identification bracelet describing the illness to facilitate quick identification in the event of an emergency. a postictal state of amnesia. A client tells the nurse that he is unclear about what an aura is. not required. A helpless client should be positioned on the side. "I will eat plenty of fresh fruits. 17. "I will drink 6 to 8 glasses of water a day. 18. gustatory.however. Which clinical manifestation does the nurse assess as a typical reaction to long-term phenytoin sodium (Dilantin) therapy? 1. A common side effect of long-term phenytoin therapy is an overgrowth of gingival tissues. this is not related to the topiramate. some may be of a psychic nature. 3. Which of the following nursing measures is inappropriate when providing oral hygiene? 1. 3. 2. an olfactory. and clients are encouraged to drink 6 to 8 glasses of water a day to dilute the urine and flush the renal tubules to avoid stone formation. the time frame is usually 2 years. 4. minimizing the risk of aspiration." 2. A lateral position helps secretions escape from the throat and mouth. The drug does not have to be taken with meals. Evaluating an aura may help identify the area of the brain from which the seizure originates. visual. 16. Opening the client's mouth with a padded tongue blade. Although eating fresh fruits is desirable from a nutritional standpoint. Excessive growth of gum tissue. overgrown tissues must be removed surgically. a symptom that occurs just before a seizure. Regular oral hygiene is an essential intervention for the client who has had a cerebrovascular accident (CVA). Weight gain 2. It is recommended. Keeping portable suctioning equipment at the bedside." 3. with the head on a small pillow. 3. "I will take the medicine before going to bed.

2. . which is a priority in the immediate treatment of the current CVA. Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major side effect of thrombolytic therapy. respirations. the primary goal is to control the client's 1. Analgesics are administered to provide pain relief. Hyperoxygenate before and after suctioning. temperature. Complete physical and history. 21. The time from the onset of stroke to t-PA treatment is a priority assessment. What is a priority nursing intervention when suctioning an unconscious client to maintain cerebral perfusion? 1. 3. It is a priority to hyperoxygenate the client before and after suctioning to prevent hypoxia and to maintain cerebral perfusion. Time of onset of current CVA. 2. A client arrives in the emergency department with an ischemic CVA and receives tissue plasminogen activator (t-PA) administration.19. pulse. During the first 24 hours after thrombolytic treatment for an ischemic CVA. Upcoming surgical procedures may need to be delayed because of the administration of t-PA administration. when the primary concerns are cerebral hemorrhage and increased intracranial pressure. Administer diuretics. A complete physical and history is not possible when a client is receiving emergency care. 3. blood pressure. 22. and the blood pressure is maintained as identified by the physician and specific to the client's ischemic tissue needs and risk of bleeding from treatment. It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. 4. 4. The cholesterol level is not a priority assessment. 2. Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a CVA have better outcomes. Bowel sounds. 4. Vital signs are monitored. 4. but this is not a priority in the first 24 hours. Provide oral hygiene. 2. Administer analgesics 3. What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic CVA? 1. although it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Which is the priority nursing assessment? 1. Upcoming surgical procedures. Pupil size and pupillary response. Current medications. Bowel sounds need to be assessed because an ileus or constipation can develop. Cholesterol level. 20. An echocardiogram is not needed for the client with a thrombotic CVA without heart problems. Echocardiogram. 3.

2. Having the client help lift herself off the bed with a trapeze is an acceptable means to move a client without causing friction burns or skin breakdown. Placing a pillow in the axilla so that the arm is away from the body. 24. What position would be inappropriate? 1. Rolling the client onto her side. The use of ankle-high tennis shoes has been found to be most effective in preventing plantar flexion (foot drop) because they add support to the foot and keep it in the correct anatomic position. The client can be expected to regain much of his functioning. but the client's foot needs to be left in correct anatomic position to prevent overextension of the muscle and tendon of the foot. The nursing assessment of the client's functional status is not a motivating factor.Oral hygiene provides asepsis and comfort. 2. 2. 3. 3. 23. The assessment does not help to predict how far the rehabilitation team can help the client to recover from the residual effects of the CVA. 4. Which nursing intervention has been found to be the most effective means of preventing plantar flexion in a client who has had a CVA with residual paralysis? 1. The rehabilitation plan will be guided by it. The primary reason for the nursing assessment of a client's functional status before and after a CVA is to guide the plan. Reposition the client every 2 hours. . Diuretics assist in reducing the intracranial pressure. Rolling the client is an acceptable method to use when changing positions as long as the client is maintained in anatomically neutral positions and her limbs are properly supported. Having the client help lift herself off the bed using a trapeze. Massage the client's feet and ankles regularly. 3. Which of the following techniques does the nurse avoid when changing a client's position in bed if the client has hemiparalysis? 1. Have the client wear ankle-high tennis shoes at intervals throughout the day. 4. The client may be lifted as long as the nurse has assistance and uses proper body mechanics to avoid injury to himself or herself or the client. 3. Positioning the hands in a slightly pronated position. The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm. Lifting the client when moving her up in bed 4. 26. The nursing assessment of a client's functional status before and after a CVA is essential. Sliding the client to move her up in bed. Why is it so important? 1. Functional status before the CVA will help predict outcomes. 2. 25. Regular repositioning and range-of-motion exercises are important interventions. only what plans can help a client who has moved from one functional level to another. Placing a pillow under the slightly flexed arm so that the hand is higher than the elbow. It will help the client recognize his physical limitations. Place the client's feet against a firm footboard. Footboards stimulate spasms and are not routinely recommended. Sliding a client on a sheet causes friction and is to be avoided. Friction injures skin and predisposes to pressure ulcer formation.

Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships. Which of the following strategies is inappropriate? 1. 2. Positioning a roll in the hand so that the fingers are barely flexed prevents the flexor muscles from overtaking the extensors. Keeping distractions to a minimum. which . 4. 2. It is better to extend the arms of the client to allow the extensor muscles to exert control over the flexor muscles and prevent contractures. 4. Liquids should be thickened to avoid aspiration. distractions should be avoided. Positioning a roll in the hand so that the fingers are barely flexed. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires 28. Introducing foods on the unaffected side allows the client to have better control over the food bolus. Forgetting the names of foods would be aphasia. 3. The client should concentrate on chewing and swallowing. the client would see only half of his plate. Restricting the diet to liquids until swallowing improves. Placing a pillow under the slightly flexed arm so that the hand is higher than the elbow prevents edema. therefore. Writing directions so client can read them. which nursing intervention is most helpful in promoting communication? 1. Placing a pillow in the axilla so that the arm is away from the body keeps the arm abducted and prevents skin from touching skin. Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A client with dysphagia (difficulty swallowing) frequently has the most difficulty ingesting thin liquids. Speaking loudly. 2. Eating food on only half of the plate. Increased preference for foods high in salt. Inability to swallow liquids. Using a picture board. There may be an increased preference for foods high in salt after a CVA. 27. For the client who is experiencing expressive aphasia. Forgetting the names of foods. therefore. The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. 29. exert control over the extensor muscles. Speaking in short sentences. 3. which are easily aspirated. Folding the arms over the chest allows the flexor muscles to flex and exert control over the already weaker extensor muscles. When voluntary muscle control is lost. which leads to skin breakdown. which are stronger. 4. Maintaining an upright position. Which food-related behaviors would the nurse observe in a client who has had a CVA that has left him with homonymous hemianopia? 1.4. Homonymous hemianopia is blindness in half of the visual field. but this would not be related to homonymous hemianopia. 3. Maintaining an upright position while eating is appropriate because it minimizes the risk of aspiration. Introducing foods on the unaffected side of the mouth. the flexor muscles.

Sit quietly with the client until the episode is over. 4. Lie in bed with the unaffected side toward the door. The client should be praised when he shows progress in his efforts to overcome handicaps. Ignoring the behavior will not affect the mood swing or the crying and may increase the client's sense of isolation. Helpfulness and sympathy. Concern and charity. 4. The nurse is teaching the client about ways to adapt to a visual disability. Tell the client that this behavior is unacceptable. To expand the visual field. An attitude of directives and firmness is inappropriate because it implies that the client can do better if he just tries harder and leaves no room for softness in the approach to overcoming a negative selfconcept. Wear a patch over one eye. 2. 32.involves a cerebral cortex lesion. the client still feels the same on the inside and has the same innate needs for his growth and developmental age group. The client who has had a CVA with residual physical handicaps becomes discouraged by his physical appearance. Attempt to divert the client's attention. Telling the client to stop is inappropriate. Place personal items on the sighted side. 33. 30. Encouragement and patience. including the lower brain stem. someone who is not like others. Regardless of the handicap. 2. A client who has brain damage may be emotionally labile and may cry or laugh for no explainable reason. the partially sighted client should be taught to turn the head from side to side when walking. Which does the nurse identify as the primary safety precaution to use? 1. An attitude of helpfulness and sympathy allows the client to assume a role of someone not ordinary. This technique helps maximize the use of remaining sight. Turn the head from side to side when walking. 3. A client is experiencing mood swings after a CVA and often has episodes of tearfulness that are distressing to the family. When offering emotional support to a client who is discouraged and has a negative selfconcept because of physical handicaps. 3. which of the following nursing interventions is inappropriate? . 3. Neglecting to do so may result in accidents. An attitude of concern and charity tends to make the client feel like a "charity case" or like someone who is given something free because of his "condition. 4. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? 1. What attitude is best for the nurse to display to help the client overcome his negative self-concept? 1." The client feels unequal to his peers or unable to fulfill the role relationships that were obtained before the CVA. the nurse should display encouragement and patience. Directives and firmness. which involves motor pathways of cranial nerves IX and X. Ignore the behavior. Crying episodes are best dealt with by attempting to divert the client's attention. 31. When communicating with a client who has aphasia. 2. Being unable to swallow liquids is dysphagia.

4. Present one thought at a time. Prevention of hemorrhage. Increased vascular permeability. 4. 3. Dissolved emboli. Make use of gestures. Encourage the client not to write messages. What is the expected outcome of thrombolytic drug therapy for CVA? 1. 2. Speak with normal volume. Thrombolytic enzyme agents are used for clients with a thrombotic CVA to dissolve emboli. or prevent further hemorrhage. 34. thus reestablishing cerebral perfusion.1. Vasoconstriction. . They do not increase vascular permeability. The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. 2. as does speaking in a normal volume and tone. 3. cause vasoconstriction. Presenting one thought at a time decreases stimuli that may distract the client. The nurse should ask the client to "show me" and should encourage the use of gestures to assist in getting the message across with minimal frustration and exhaustion for the client.