STROKE - NCLEX
b. Infuse normal saline intravenously at 75 mL/hr.
After a patient experienced a brief episode of tinnitus,
diplopia, and dysarthria with no residual effects, the nurse
anticipates teaching the patient about
a. cerebral aneurysm clipping.
b. heparin intravenous infusion.
c. oral low-dose aspirin therapy.
d. tissue plasminogen activator (tPA).
A 68-year-old patient is being admitted with a possible
stroke. Which information from the assessment indicates
that the nurse should consult with the health care provider
before giving the prescribed aspirin?
a. The patient has dysphasia.
b. The patient has atrial fibrillation.
c. The patient reports that symptoms began with a severe
headache.
d. The patient has a history of brief episodes of right-sided
hemiplegia.
A 73-year-old patient with a stroke experiences facial
drooping on the right side and right-sided arm and leg
paralysis. When admitting the patient, which clinical
manifestation will the nurse expect to find?
a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided tendon reflexes
d. Difficulty comprehending instructions
During the change of shift report a nurse is told that a patient
has an occluded left posterior cerebral artery. The nurse will
anticipate that the patient may have
a. dysphasia.
b. confusion.
c. visual deficits.
d. poor judgment.
When teaching about clopidogrel (Plavix), the nurse will tell
the patient with cerebral atherosclerosis
a. to monitor and record the blood pressure daily.
b. that Plavix will dissolve clots in the cerebral arteries.
c. that Plavix will reduce cerebral artery plaque formation.
d. to call the health care provider if stools are bloody or tarry.
A patient with carotid atherosclerosis asks the nurse to
describe a carotid endarterectomy. Which response by the
nurse is accurate?
a. "The obstructing plaque is surgically removed from an
artery in the neck."
b. "The diseased portion of the artery in the brain is replaced
with a synthetic graft."
c. "A wire is threaded through an artery in the leg to the clots
in the carotid artery and the clots are removed."
d. "A catheter with a deflated balloon is positioned at the
narrow area, and the balloon is inflated to flatten the plaque."
A patient admitted with possible stroke has been aphasic for
3 hours and his current blood pressure (BP) is 174/94 mm
Hg. Which order by the health care provider should the
nurse question?
a. Keep head of bed elevated at least 30 degrees.
c. Administer tissue plasminogen activator (tPA) per
protocol.
d. Administer a labetalol (Normodyne) drip to keep BP less
than 140/90 mm Hg.
A 56-year-old patient arrives in the emergency department
with hemiparesis and dysarthria that started 2 hours
previously, and health records show a history of several
transient ischemic attacks (TIAs). The nurse anticipates
preparing the patient for
a. surgical endarterectomy.
b. transluminal angioplasty.
c. intravenous heparin administration.
d. tissue plasminogen activator (tPA) infusion.
A female patient who had a stroke 24 hours ago has
expressive aphasia. The nurse identifies the nursing
diagnosis of impaired verbal communication. An appropriate
nursing intervention to help the patient communicate is to
a. ask questions that the patient can answer with "yes" or
"no."
b. develop a list of words that the patient can read and
practice reciting.
c. have the patient practice her facial and tongue exercises
with a mirror.
d. prevent embarrassing the patient by answering for her if
she does not respond.
A 72-year-old patient who has a history of a transient
ischemic attack (TIA) has an order for aspirin 160 mg daily.
When the nurse is administering medications, the patient
says, "I don't need the aspirin today. I don't have a fever."
Which action should the nurse take?
a. Document that the aspirin was refused by the patient.
b. Tell the patient that the aspirin is used to prevent a fever.
c. Explain that the aspirin is ordered to decrease stroke risk.
d. Call the health care provider to clarify the medication
order.
For a patient who had a right hemisphere stroke the nurse
establishes a nursing diagnosis of
a. risk for injury related to denial of deficits and
impulsiveness.
b. impaired physical mobility related to right-sided
hemiplegia.
c. impaired verbal communication related to speech-
language deficits.
d. ineffective coping related to depression and distress about
disability.
A patient in the clinic reports a recent episode of dysphasia
and left-sided weakness at home that resolved after 2 hours.
The nurse will anticipate teaching the patient about
a. alteplase (tPA).
b. aspirin (Ecotrin).
c. warfarin (Coumadin).
d. nimodipine (Nimotop).
When caring for a patient with a new right-sided
homonymous hemianopsia resulting from a stroke, which
intervention should the nurse include in the plan of care?
a. Apply an eye patch to the right eye.
b. Approach the patient from the right side.
c. Place objects needed on the patient's left side.
d. Teach the patient that the left visual deficit will resolve.
A 58-year-old patient with a left-brain stroke suddenly bursts
into tears when family members visit. The nurse should
a. use a calm voice to ask the patient to stop the crying
behavior.
b. explain to the family that depression is normal following a
stroke.
c. have the family members leave the patient alone for a few
minutes.
d. teach the family that emotional outbursts are common
after strokes.
The nurse identifies the nursing diagnosis of imbalanced
nutrition: less than body requirements related to impaired
self-feeding ability for a left-handed patient with left-sided
hemiplegia. Which intervention should be included in the
plan of care?
a. Provide a wide variety of food choices.
b. Provide oral care before and after meals.
c. Assist the patient to eat with the right hand.
d. Teach the patient the "chin-tuck" technique
Which stroke risk factor for a 48-year-old male patient in the
clinic is most important for the nurse to address?
a. The patient is 25 pounds above the ideal weight.
b. The patient drinks a glass of red wine with dinner daily.
c. The patient's usual blood pressure (BP) is 170/94 mm Hg.
d. The patient works at a desk and relaxes by watching
television.
A 40-year-old patient has a ruptured cerebral aneurysm and
subarachnoid hemorrhage. Which intervention will be
included in the care plan?
a. Apply intermittent pneumatic compression stockings.
b. Assist to dangle on edge of bed and assess for dizziness.
c. Encourage patient to cough and deep breathe every 4
hours.
d. Insert an oropharyngeal airway to prevent airway
obstruction.
A patient in the emergency department with sudden-onset
right-sided weakness is diagnosed with an intracerebral
hemorrhage. Which information about the patient is most
important to communicate to the health care provider?
a. The patient's speech is difficult to understand.
b. The patient's blood pressure is 144/90 mm Hg.
c. The patient takes a diuretic because of a history of
hypertension.
d. The patient has atrial fibrillation and takes warfarin
(Coumadin).
A 47-year-old patient will attempt oral feedings for the first
time since having a stroke. The nurse should assess the gag
reflex and then
a. order a varied pureed diet.
b. assess the patient's appetite.
c. assist the patient into a chair.
d. offer the patient a sip of juice.
A patient with left-sided weakness that started 60 minutes
earlier is admitted to the emergency department and
diagnostic tests are ordered. Which test should be done
first?
a. Complete blood count (CBC)
b. Chest radiograph (Chest x-ray)
c. 12-Lead electrocardiogram (ECG)
d. Noncontrast computed tomography (CT) scan
A male patient who has right-sided weakness after a stroke
is making progress in learning to use the left hand for
feeding and other activities. The nurse observes that when
the patient's wife is visiting, she feeds and dresses him.
Which nursing diagnosis is most appropriate for the patient?
a. Interrupted family processes related to effects of illness of
a family member
b. Situational low self-esteem related to increasing
dependence on spouse for care
c. Disabled family coping related to inadequate
understanding by patient's spouse
d. Impaired nutrition: less than body requirements related to
hemiplegia and aphasia
Nurses in change-of-shift report are discussing the care of a
patient with a stroke who has progressively increasing
weakness and decreasing level of consciousness (LOC).
Which nursing diagnosis do they determine has the highest
priority for the patient?
a. Impaired physical mobility related to weakness
b. Disturbed sensory perception related to brain injury
c. Risk for impaired skin integrity related to immobility
d. Risk for aspiration related to inability to protect airway
Several weeks after a stroke, a 50-year-old male patient has
impaired awareness of bladder fullness, resulting in urinary
incontinence. Which nursing intervention will be best to
include in the initial plan for an effective bladder training
program?
a. Limit fluid intake to 1200 mL daily to reduce urine volume.
b. Assist the patient onto the bedside commode every 2
hours.
c. Perform intermittent catheterization after each voiding to
check for residual urine.
d. Use an external "condom" catheter to protect the skin and
prevent embarrassment.
Which information about the patient who has had a
subarachnoid hemorrhage is most important to communicate
to the health care provider?
a. The patient complains of having a stiff neck.
b. The patient's blood pressure (BP) is 90/50 mm Hg.
c. The patient reports a severe and unrelenting headache.
d. The cerebrospinal fluid (CSF) report shows red blood cells
(RBCs).
The nurse is caring for a patient who has been experiencing
stroke symptoms for 60 minutes. Which action can the nurse
delegate to a licensed practical/vocational nurse (LPN/LVN)?
a. Assess the patient's gag and cough reflexes.
b. Determine when the stroke symptoms began.
c. Administer the prescribed short-acting insulin.
d. Infuse the prescribed IV metoprolol (Lopressor).
After receiving change-of-shift report on the following four
patients, which patient should the nurse see first?
a. A 60-year-old patient with right-sided weakness who has
an infusion of tPA prescribed
b. A 50-year-old patient who has atrial fibrillation and a new
order for warfarin (Coumadin)
c. A 40-year-old patient who experienced a transient
ischemic attack yesterday who has a dose of aspirin due
d. A 30-year-old patient with a subarachnoid hemorrhage 2
days ago who has nimodipine (Nimotop) scheduled
The nurse is caring for a patient who has just returned after
having left carotid artery angioplasty and stenting. Which
assessment information is of most concern to the nurse?
a. The pulse rate is 102 beats/min.
b. The patient has difficulty speaking.
c. The blood pressure is 144/86 mm Hg.
d. There are fine crackles at the lung bases.
A 70-year-old female patient with left-sided hemiparesis
arrives by ambulance to the emergency department. Which
action should the nurse take first?
a. Monitor the blood pressure.
b. Send the patient for a computed tomography (CT) scan.
c. Check the respiratory rate and effort.
d. Assess the Glasgow Coma Scale score.
C: Opening the client's mouth with a padded tongue blade
D: Cleaning the clients mouth and teeth with toothbrush
A 78 year old client is admitted to the ED with numbness and
weakness of the left arm and slurred speech. Which nursing
intervention is priority?
A: Prepare to administer recombinant tissue plasminogen
activator (rt-PA)
B: Discuss the precipitating factors that caused the
symptoms
C: Schedule a STAT CT scan of head
D: Notify speech pathologist for emergency consult
A client arrives at the ED with ischemic stroke and receives
tissue plasminogen activator (t-PA) administration. Which is
priority nursing assessment?
A: Current medications
B: Complete physical and history
C: Time of onset of current stroke
D: Upcoming surgical procedures
During the first 24 hours after thrombolytic therapy for
ischemic stroke, the primary goal is to control the clients:
A: Pulse
B: Respiration
C: BP
D: Temperature
What is a priority nursing assessment in the first 24 hours
after admission of client with a thrombotic stroke?
A: Cholesterol level
B: Pupil size and papillary response
C: Vowel sounds
D: Echo

The home health nurse is caring for an 81-year-old who had What is expected outcome of thrombolytic drug therapy?
a stroke 2 months ago. Based on information shown in the A: Increased vascular permeability
accompanying figure from the history, physical assessment, B: Vasoconstriction
and physical therapy/occupational therapy, which nursing C: Dissolved emboli
diagnosis is the highest priority for this patient? D: Prevention of hemorrhage
a. Impaired transfer ability
b. Risk for caregiver role strain The client diagnosed with A-fib, has experienced a TIA.
c. Ineffective health maintenance Which medication would the nurse anticipate being ordered
d. Risk for unstable blood glucose level for the client on discharge?
A: PO anticoagulant medication
A 63-year-old patient who began experiencing right arm and B: Beta-blocker medication
leg weakness is admitted to the emergency department. In C: Anti-hyperuricemic medication
which order will the nurse implement these actions included D: Thrombolytic medication
in the stroke protocol?
a. Obtain computed tomography (CT) scan without contrast. Which client would the nurse identify as being MOST at risk
b. Infuse tissue plasminogen activator (tPA). for experiencing a CVA?
c. Administer oxygen to keep O2 saturation >95%. A: 55yr. old African American Male
d. Use National Institute of Health Stroke Scale to assess B: 84yr. old Japanese female
patient. C: 67yr. old white male
D: 39yr. old prego female
Regular oral hygiene is an essential intervention for the
client who has had a stroke. Which of the following nursing Which assessment data would indicate to nurse that the
measures is inappropriate when providing oral hygiene? client would be at risk for hemorrhagic stroke?
A: Placing client on back with small pillow under the head A: Blood glucose level of 480mg/dL
B: Keeping portable suctioning equipment at the bedside B: Right sided carotid bruit
C: BP of 220/120 mm Hg
D: Presence of bronchogenic carcinoma
The Nurse and UAP are caring for a client with right-sided
paralysis. Which action by the UAP requires the nurse to
intervene?
A: Place gait belt around client's waster prior to ambulating
B: Places client on back with client's head to the side
C: Places her hand under the client's right axilla to help them
move up in bed
D: Praises the client for attempting to perform ADL's
independently
In promoting health maintenance for prevention of strokes,
the nurse understands that the highest risk for the most
common type of stroke is present in
a. African Americans
b. women who smoke
c.individuals with hypertension and diabetes
d. those who are obese with high dietary fat intake
A patient comes to the emergency department immediately
after experiencing numbness of the face and an inability to
speak, but while the patient awaits examination, the
symptoms disappear and the patient request discharge. The
nurse stresses that it is important for the patient to be
evaluated primarily because
a. the patient has probably experienced an asymptomatic
lacunar stroke
b. the symptoms are likely to return and progress to
worsening neurologic deficit in the next 24 hours
c. neurologic deficits that are transient occur most often as a
result of small hemorrhages that clot off
d. the patient has probably experienced a transient ischemic
attack (TIA), which is a sign of progressive cerebral vascular
disease
A patient is admitted to the hospital with a left hemiplegia. To
determine the size and location and to ascertain whether a
stroke is ischemic or hemorrhagic, the nurse anticipates that
the health care provider will request a
a. CT scan
b. lumbar puncture
c. cerebral arteriogram
d. positron emission tomography (PET)
The priority intervention in the emergency department for the
patient with a stroke is
a. intravenous fluid replacement
b. administration of osmotic diuretics to reduce cerebral
edema
c. initiation of hypothermia to decrease the oxygen needs of
the brain
d. maintenance of respiratory function with a patent airway
and oxygen administration
A nursing intervention is indicated for the patient with
hemiplegia is
a. the use of a footboard to prevent plantar flexion
b. immobilization of the affected arm against the chest with a
sling
c. positioning the patient in bed with each joint lower than the
joint proximal to it
d. having the patient perform passive ROM of the affected
limb with the unaffected limb
To promote communication during rehabilitation of the
patient with aphasia, an appropriate nursing intervention is to
a. use gestures, pictures, and music to stimulate patient
responses
b. talk about activities of daily living (ADLs) that are familiar
to the patient
c. structure statements so that patient does not have to
respond verbally
d. use flashcards with simple words and pictures to promote
language recall
SEIZURE – NCLEX
a nurse understands that a client with a seizure disorder who
frequently experiences an aura is describing
a. sensory warning that seizure is imminent
b. continuous seizure state in which seizures occur in rapid
succession
c. period of sleepiness following the seizure during which
arousal is difficult
d. brief loss of consciousness accompanied by staring
a client with a seizure disorder is being discharged. the
clients family has many questions about what to do if the
client has a seizure at home. the nurse tells the family
members that the first action to take in the event of a seizure
is to
a. support and protect the clients head
b. ease the client to the floor if seated or standing
c. loosen constrictive clothing
d. turn the client on his side
a client is admitted for surgical repair on an inguinal hernia.
the client has a seizure disorder and states that he thinks he
is about to have a seizure. which of the following nursing
interventions should be implemented (select all)
a. provide privacy
b. ease the client to the floor if standing
c. move furniture away from the client
d. loosen the clients clothing
e. insert airway or padded tongue blade
f. protect the clients head with padding
g. restrain the client to protect from injury
which of the following is a priority intervention for a nurse
caring for a client who has just experienced a generalized
seizure
a. keep the client in a side lying position
b. take the clients vs
c. reorient the client to the environment
d. check the client for injuries
a client calls the clinic and tells the nurse that her morning
dose of phenytoin (dilantin) was accidentally skipped and it
is now 3 hr before the next dose is due. the client typically
takes phenytoin 3 times a day. which of the following actions
should the nurse tell the client to take
a. take a double dose of the med at the next scheduled time
b. wait until the next scheduled time and take a reg dose
c. take the skipped dose now and take another dose at the
next scheduled time
d. wait until the next day to take additional doses and then
resume the reg schedule
a nurse is providing education for a client who is scheduled
to have an eeg the following day. which of the following
instructions is appropriate to provide
a. decaffeinated coffee can be consumed the morning of the
procedure
b. hair should not be washed prior to the procedure
c. food may not be consumed the morning of the procedure
d. get plenty of sleep prior to the test
A nurse is providing discharge instructions to a female client
who has a prescription for phenytoin (Dilantin).
Which of the following information should the nurse include?
A.Consider taking oral contraceptives when on this
medication.
B.Watch for receding gums when taking the medication.
C.Take the medication at the same time every day.
D.Provide a urine sample to determine therapeutic levels of
the medication
A nurse is reviewing trigger factors that can cause seizures
with a client who has a new diagnosis of generalized
seizures. Which of the following information should the nurse
include in this review? (Select all that apply.)
A.Overwhelming fatigue should be avoided.
B.Caffeinated products should be removed from the diet.
C.Looking at flashing lights should be limited.
D.Aerobic exercise may be performed.
E.Episodes of hypoventilation should be limited.
F.Use of aerosol hairspray is recommended
A nurse is completing discharge teaching to a client who has
seizures and received a vagal nerve stimulator to decrease
seizure activity. Which of the following information should the
nurse include in
the teaching?
A.The use of a microwave to heat food is permitted.
B.Inform a provider to order only a MRI when a scan is
needed.
C.Place a magnet over the implantable device when an aura
occurs.
D.The use of ultrasound diathermy for pain management is
recommended
The male client is sitting in the chair and his entire body is
rigid with his arms and
legs contracting and relaxing. The client is not aware of what
is going on and is
making guttural sounds. Which action should the nurse
implement first?
1. Push aside any furniture.
2. Place the client on his side.
3. Assess the client's vital signs.
4. Ease the client to the floor.
The occupational health nurse is concerned about
preventing occupation-related
acquired seizures. Which intervention should the nurse
implement?
1. Ensure that helmets are worn in appropriate areas.
2. Implement daily exercise programs for the staff.
3. Provide healthy foods in the cafeteria.
4. Encourage employees to wear safety glasses.
The client is scheduled for an electroencephalogram (EEG)
to help diagnose a
seizure disorder. Which preprocedure teaching should the
nurse implement?
1. Tell the client to take any routine antiseizure medication
prior to the EEG.
2. Tell the client not to eat anything for eight (8) hours prior
to the procedure.
3. Instruct the client to stay awake for 24 hours prior to the
EEG.
4. Explain to the client that there will be some discomfort
during the procedure.
The nurse enters the room as the client is beginning to have
a tonic-clonic seizure.
What action should the nurse implement first?
1. Note the first thing the client does in the seizure.
2. Assess the size of the client's pupils.
3. Determine if the client is incontinent of urine or stool.
4. Provide the client with privacy during the seizure.
The client who just had a three (3)-minute seizure has no
apparent injuries and is
oriented to name, place, and time but is very lethargic and
just wants to sleep. Which
intervention should the nurse implement?
1. Perform a complete neurological assessment.
2. Awaken the client every 30 minutes.
3. Turn the client to the side and allow the client to sleep.
4. Interview the client to find out what caused the seizure.
The unlicensed assistive personnel (UAP) is attempting to
put an oral airway in the
mouth of a client having a tonic-clonic seizure. Which action
should the primary
nurse take?
1. Help the UAP to insert the oral airway in the mouth.
2. Tell the UAP to stop trying to insert anything in the mouth.
3. Take no action because the UAP is handling the situation.
4. Notify the charge nurse of the situation immediately.
The client is prescribed phenytoin (Dilantin), an
anticonvulsant, for a seizure
disorder. Which statement indicates the client understands
the discharge teaching
concerning this medication?
1. "I will brush my teeth after every meal."
2. "I will check my Dilantin level daily."
3. "My urine will turn orange while on Dilantin."
4. "I won't have any seizures while on this medication."
The client is admitted to the intensive care department (ICD)
experiencing status
epilepticus. Which collaborative intervention should the
nurse anticipate?
1. Assess the client's neurological status every hour.
2. Monitor the client's heart rhythm via telemetry.
3. Administer an anticonvulsant medication by intravenous
push.
4. Prepare to administer a glucocorticosteroid orally.
The client has been newly diagnosed with epilepsy. Which
discharge instructions
should be taught to the client? Select all that apply.
1. Keep a record of seizure activity.
2. Take tub baths only; do not take showers.
3. Avoid over-the-counter medications.
4. Have anticonvulsant medication serum levels checked
regularly.
5. Do not drive alone; have someone in the car.
Which statement by the female client indicates that the
client understands factors
that may precipitate seizure activity?
1. "It is all right for me to drink coffee for breakfast."
2. "My menstrual cycle will not affect my seizure disorder."
3. "I am going to take a class in stress management."
4. "I should wear dark glasses when I am out in the sun."
The nurse asks the male client with epilepsy if he has auras
with his seizures. The
client says, "I don't know what you mean. What are auras?"
Which statement by the
nurse would be the best response?
1. "Some people have a warning that the seizure is about to
start."
2. "Auras occur when you are physically and psychologically
exhausted."
3. "You're concerned that you do not have auras before your
seizures?"
4. "Auras usually cause you to be sleepy after you have a
seizure."
The nurse educator is presenting an in-service on seizures.
Which disease process is
the leading cause of seizures in the elderly?
1. Alzheimer's disease.
2. Parkinson's disease.
3. Cerebral vascular accident (stroke).
4. Brain atrophy due to aging.
The nurse is discharging a patient admitted with a transient
ischemic attack (TIA). For which medications might the
nurse expect to provide discharge instructions (select all that
apply)?
A. Clopidogrel (Plavix)
B. Enoxaparin (Lovenox)
C. Dipyridamole (Persantine)
D. Enteric-coated aspirin (Ecotrin)
E. Tissue plasminogen activator (tPA)
Which sensory-perceptual deficit is associated with left-sided
stroke (right hemiplegia)?
A. Overestimation of physical abilities
B. Difficulty judging position and distance
C. Slow and possibly fearful performance of tasks
D. Impulsivity and impatience at performing tasks
The female patient has been brought to the ED with a
sudden onset of a severe headache that is different from any
other headache she has had previously. When considering
the possibility of a stroke, which type of stroke should the
nurse know is most likely occurring?
A. TIA
B. Embolic stroke
C. Thrombotic stroke
D. Subarachnoid hemorrhage
The patient with diabetes mellitus has had a right-sided
stroke. Which nursing intervention should the nurse plan to
provide for this patient related to expected manifestations of
this stroke?
A. Safety measures
B. Patience with communication
C. Mobility assistance on the right side
D. Place food in the left side of patient's mouth.
The nurse in a primary care provider's office is assessing
several patients today. Which patient is most at risk for a
stroke?
A. A 92-year-old female who takes warfarin (Coumadin) for
atrial fibrillation.
B. A 28-year-old male who uses marijuana after
chemotherapy to control nausea.
C. A 42-year-old female who takes oral contraceptives and
has migraine headaches.
D. A 72-year-old male who has hypertension and diabetes
mellitus and smokes tobacco.
A patient has been receiving scheduled doses of phenytoin
(Dilantin) and begins to experience diplopia. The nurse
immediately assesses the patient for
A. an aura or focal seizure.
B. nystagmus or confusion.
C. abdominal pain or cramping.
D. irregular pulse or palpitations.
Which characteristic of a patient's recent seizure is
consistent with a focal seizure?
A. The patient lost consciousness during the seizure.
Incorrect
B. The seizure involved lip smacking and repetitive
movements.
C. The patient fell to the ground and became stiff for 20
seconds.
D. The etiology of the seizure involved both sides of the
patient's brain.
Which nursing diagnosis is likely to be a priority in the care
of a patient with myasthenia gravis (MG)?
A. Acute confusion
B. Bowel incontinence
C. Activity intolerance
D. Disturbed sleep pattern
The patient with type 1 diabetes mellitus with hypoglycemia
is having a seizure. Which medication should the nurse
anticipate administering to stop the seizure?
A. IV dextrose solution
B. IV diazepam (Valium)
C. IV phenytoin (Dilantin)
D. Oral carbamazepine (Tegretol)
The nurse provides information to the caregiver of a 68-year-
old man with epilepsy who has tonic-clonic seizures. Which
statement, if made by the caregiver, requires further
teaching?
A. "It is normal for a person to be sleepy after a seizure."
B. "I should call 911 if breathing stops during the seizure."
C. "The jerking movements may last for 30 to 40 seconds."
D. "Objects should not be placed in the mouth during a
seizure."
The nurse is caring for a group of patients on a medical unit.
After receiving report, which patient should the nurse see
first?
A. A 42-year-old patient with multiple sclerosis who was
admitted with sepsis
B. A 72-year-old patient with Parkinson's disease who has
aspiration pneumonia
C. A 38-year-old patient with myasthenia gravis who
declined prescribed medications
D. A 45-year-old patient with amyotrophic lateral sclerosis
who refuses enteral feedings
A client receiving phenytoin (Dilantin) has been experiencing
fluctuating serum blood levels of the medication.
Development of which symptoms in the client should prompt
the nurse to notify the primary health care provider
immediately? (Select all that apply.)
A. GI cramping and diarrhea
B. Migraine headaches and nausea
C. Dry skin and constipation
D. Double vision and lethargy
A client receiving digoxin (Lanoxin) therapy is being treated
for status epilepticus with diazepam (Valium). The nurse
places priority on:
A. Holding the digoxin until the seizure has subsided.
B. Monitoring the client for nausea and GI cramping.
C. Keeping the client in a high Fowler's position.
D. Instructing the client to eat foods high in potassium.
The nurse should question the use of barbiturates for the
treatment of seizure activity if prescribed for which of the
following clients?
A. 30-year-old pregnant female
B. 24-year-old male with new diagnosis of seizures
C. 55-year-old female with history of diabetes mellitus
D. 45-year-old male with history of hypertension
The client, age 8, is prescribed valproic acid (Depokene) for
treatment of a seizure disorder. The nurse should monitor
the client closely for:
A. Vitamin B deficiency.
B. Restlessness and agitation.
C. Hyperthermia.
D. Respiratory distress
The nurse completes a history and physical on a client
admitted with exacerbation of a seizure disorder. What
datum collected by the nurse requires intervention?
A. History of asthma
B. History of diabetes mellitus
C. Use of herb Ginkgo biloba
D. Use of aspirin daily
The client is prescribed clonazepam (Klonopin) for treatment
of a seizure disorder. Appropriate nursing action includes:
A. Administrating with other CNS depressants.
B. Maintaining available dose for treating status epilepticus.
C. Determining the pregnancy status of the client.
D. Assuring the client that a history of glaucoma will not
affect treatment.
The nurse giving discharge teaching for a client receiving
carbamazepine (Tegretol) should include:
A. Monitor blood glucose, and report decreased levels.
B. Expect a discoloration of the contact lenses.
C. Expect an orange discoloration of urine.
D. Report unusual bleeding or bruises to the health care
provider immediately.
A patient receives phenytoin (Dilantin) for partial seizures.
Which medication will require a higher-than-normal dosage
when taken by the patient during this therapy?
A) Tiagabine (Gabritril)
B) Lamotrigine (Lamictal)
C) Gabapentin (Neurontin)
D) Phenobarbital (Luminal)
The nurse prepares a female patient who takes
phenobarbital (Luminal) and oral contraceptives for
discharge. Which intervention is the nurse's priority before
discharge?
A) Planning for regular exercise in a safe setting
B) Making a medication reminder sign for the home
C) Instructing the patient to get help before climbing stairs
D) Helping the patient plan another form of birth control
The patient is receiving IV antiepileptic therapy. Which
parenteral antiepileptic drug is effective against generalized
seizures?
A) Phenytoin (Dilantin)
B) Fosphenytoin (Cerebyx)
C) Phenobarbital (Luminal)
D) Valproic acid (Depakene)
What information should the nurse provide to a patient who
will self-administer an antiepileptic agent for the first time at
home?
A) Report any vision or hearing problems with levetiracetam
(Keppra).
B) Stir phenobarbital (Luminal) elixir into a cold carbonated
beverage.
C) Have a complete blood count monthly while taking
carbamazepine (Tegretol).
D) Administer pregabalin (Lyrica) every morning on an
empty stomach.
The nurse finds a patient on the floor who is unresponsive
but exhibiting spasms of the trunk and flexion of the arm
alternating with periods of relaxation. Which finding should
the nurse include in the nursing documentation?
A) Patient on floor as a result of loss of consciousness
B) Patient fallen to floor, exhibiting tonic convulsions
C) Patient exhibiting arm flexion with trunk spasms
D) Patient fallen to floor as a result of tonic-clonic seizure
A patient who needs an antiepileptic medication for tonic-
clonic seizures is unresponsive. Which antiepileptic
medication(s) should the nurse avoid administering to this
patient? (Choose all that apply.)
A) Tiagabine (Gabitril)
B) Phenytoin (Dilantin)
C) Topiramate (Topamax)
D) Gabapentin (Neurontin)
E) ethosuximide (Zarontin)
F) Phenobarbital (Luminal)
After the nurse administers lidocaine for ventricular
tachycardia, the patient experiences status epilepticus.
Which medication could be administered to treat both
problems?
A) Diazepam (Valium)
B) Phenytoin (Dilantin)
C) Phenobarbital (Luminal)
D) Carbamazepine (Tegretol)
The nurse prepares to administer carbamazepine (Tegretol)
to a patient receiving temazepam (Restoril). Which risk to
the patient is increased by the concomitant administration of
these medications?
A) Inability to have sound sleep
B) Incidence of absence seizures
C) Carbamazepine toxicity
D) Circulatory collapse
A patient's pharmacotherapy includes valproic acid
(Depakene), and the prescriber wants to add carbamazepine
(Tegretol). After the new medication is added, which
phenomenon is the nurse most likely to observe in the
patient?
A) Less amnesia after a convulsion
B) Increased number of convulsions
C) Changes in nature of convulsions
D) Improved level of consciousness
What is the best diagnostic study with which to determine
the type of seizure activity while the patient is experiencing
the seizure?
A) Electroencephalogram (EEG)
B) Computed tomography (CT)
C) Magnetic resonance imaging (MRI)
D) Positron emission tomography (PET)
Which information should be given to the client taking
phenytoin (Dilantin)?
A. Taking the medication with meals will increase its
effectiveness.
B. The medication can cause sleep disturbances
C. More frequent dental appointments will be needed for
special gum care.
D. The medication decreases the effects of oral contra-
ceptives.
The nurse is teaching a patient who is newly diagnosed with
epilepsy about her disease. Which statement made by the
nurse best describes the goals of
antiepilepsy medication therapy?
A) "With proper treatment we can completely eliminate your
seizures."
B) "Our goal is to reduce your seizures to an extent that
helps you live a normal life."
C) "Epilepsy medication does not reduce seizures in most
patients."
D) "These drugs will help control your seizures until you
have surgery."
The nurse is preparing to give ethosuximide (Zarontin). The
nurse understands that this drug is only indicated for which
seizure type?
A) Tonic-clonic
B) Absence
C) Simple partial
D) Complex partial
The nurse is conducting discharge teaching related to a new
prescription for phenytoin (Dilantin). Which statements are
appropriate to include in the teaching for this patient and his
family? Select all that apply.
A) "Be sure to call the clinic if you or your family notice
increased anxiety or agitation."
B) "You may have some mild sedation. Do not drive until you
know how this drug will affect you."
C) "This drug may cause easy bruising. If you notice this, call
the clinic immediately."
D) "It is very important to have good oral hygiene and visit
your dentist regularly."
E) "You may continue to have wine with your evening meals
but only in moderation."
Which of the following statements made by a client taking
phenytoin indicates understanding of the nurse's teaching?
A. "I will increase the dose if my seizures don't stop."
B. "I don't need to contact my health care provider before
taking an over-the-counter cold remedy."
C. "I will take good care of my teeth and see my dentist
regularly."
D. "I cannot take this drug with food."
A 20-year-old client presents to the clinic with complaints of
breast tenderness, nausea, vomiting, and absence of
menses for 2 months. She has a history of a seizure disorder
well controlled with carbamazepine (Tegretol). She tells the
nurse that she has been taking her oral contraceptives as
directed, but she wonders if she might be pregnant. The
nurse's best response to her concern should be which of the
following?
A. "You can't be pregnant if you have been taking your oral
contraceptives correctly."
B. "Carbamazepine can decrease the effectiveness of oral
contraceptive drugs, so we need to do a pregnancy test."
C. "There is no need to worry. Oral contraceptives are very
effective."
D. "Taking antiseizure drugs with oral contraceptives
significantly decreases your risk of getting pregnant."