NUR 145

SAS 36
MANGHIHILOT, LEAFLOR ANN CRAVE
BSN 2

1.) B.
- Absence seizure are one form of generalized seizures, formerly known
as petit mal seizures.
2.) D.
- The child has a diagnosis of febrile seizures. Precautions to prevent
injury and promote safety should take precedence.
3.) C.
- Adverse side effects of Dilantin include agranulocytosis and aplastic
anemia; therefore, the client will need frequent CBCs.
4.) C.
- The priority action during a generalized tonic-clonic seizure is to protect
the airway. Administration of lorazepam should be the next action, since
it will act rapidly to control the seizure. Although oxygen may be useful
during the postictal phase, the hypoxemia during tonic-clonic seizures is
caused by apnea.
5.) B.
- When used to treat status epilepticus, diazepam may be given every 10
to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can
repeat the regimen in 2 to 4 hours, if necessary, but the total dose
shouldn't exceed 100 mg in 24 hours.
6.) D.
- Patient with a seizure disorder should not take over-the-counter
medications without consulting with the physician first. The other three
statements are appropriate teaching points for patients with seizures
disorders and their families.
7.) D.
- Absence seizures, formerly known as petit mal seizures, are
characterized by a brief lapse in consciousness accompanied by rapid
 eye blinking, lip smacking, and minor myoclonus of the upper
extremities.
8.) D.
- Protecting the client from injury is the immediate priority during a
seizure.
9.) D.
- Nursing care for a child having a seizure includes, maintaining airway
patency, ensuring safety, administering medications, and providing
emotional support. Since the seizure has already started, nothing should
be forced into the child's mouth and they should not be moved.
10.) B.
- Nursing actions during a seizure include providing for privacy, loosening
restrictive B clothing, removing the pillow and raising side rails in the
bed, and placing the client on one side with the head flexed forward, if
possible, to allow the tongue to fall forward and facilitate drainage. The
limbs are never restrained because the strong muscle contractions could
cause the client harm.