Which of the following is contraindicated for a client with seizure precautions?
Encouraging him to perform his own personal hygiene.
Allowing him to wear his own clothing.
Assessing oral temperature with a glass thermometer.
Encouraging him to be out of bed.
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.
Dextrose 50%, 50 mL IV bolus.
Flumazenil, 0.2 mg IV.
Thiamine, 100 mg IV
Naloxone, 0.45 mg IV.
Which of the following will the nurse observe in the client in the ictal phase of a generalized grand mal (tonic-clonic) seizure?
Jerking in one extremity that spreads gradually to adjacent areas.
Vacant staring and an abrupt cessation of all activity.
Facial grimaces, patting motions, and lip smacking.
Loss of consciousness, body stiffening, and violent muscle contractions.
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?
"You must shampoo your hair tonight to remove all oil and dirt."
"You may drink fluids until midnight; but after that drink nothing until the scan is completed."
"You will have some hair shaved to attach the small electrode to your scalp."
"You will need to hold your head very still during the examination."
For breakfast on the morning a client is to have an electroencephalogram (EEG), the client is served a soft-boiled egg, toast with butter and marmalade, orange juice, and coffee. Which of the following would the nurse do?
Remove all the food.
Remove the coffee.
Remove the toast, butter, and marmalade only.
Substitute vegetable juice for the orange juice.
Upon awakening from his first tonic-clonic seizure, a 20-year-old client asks the nurse, "What caused me to have a seizure? I've never had one before." 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?
Head trauma.
Electrolyte imbalance.
Congenital defect.
Epilepsy.
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)?
Take all the medication until it is gone.
Notify the physician if vision changes occur.
Store gabapentin in the refrigerator.
Take gabapentin with an antacid to protect against ulcers.
What is the priority nursing intervention in the postictal phase of a seizure?
Reorient the client to time, person, and place.
Determine the client's level of sleepiness.
Assess the client's breathing pattern.
Position the client comfortably.
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?
Maintain the client on bed rest
Administer butabarbital sodium (phenobarbital) 30 mg orally, three times per day.
Close the door to the room to minimize stimulation.
Administer carbamazepine (Tegretol) 200 mg orally, twice per day.
What nursing assessments should be documented at the beginning of the ictal phase of a seizure?
Heart rate, respirations, pulse oximeter, and blood pressure
Last dose of anticonvulsant and circumstances at the time.
Type of visual, auditory, and olfactory aura the client experienced.
Movement of the head and eyes and muscle rigidity.
Which clinical manifestation does the nurse expect in the client in the postictal phase of grand mal seizure?
Drowsiness.
Inability to move.
Paresthesia.
Hypotension.
A client with seizures asks the nurse how phenytoin sodium (Dilantin) will help. Based on knowledge of the drug's action, what is the nurse's best response?
It corrects the abnormal synthesis of norepinephrine in the body.
Transmission of abnormal impulses in the spinal cord is depressed.
The responsiveness of neurons in the brain to abnormal impulses is reduced.
It interrupts the flow of abnormal impulses from peripheral neurons in the viscera to the brain.
When preparing to teach a client about phenytoin sodium (Dilantin) therapy, the nurse would urge the client not to stop the drug suddenly because
physical dependency on the drug develops over time.
status epilepticus may develop.
a hypoglycemic reaction develops.
heart block is likely to develop.
client states that she is afraid she will not be able to drive again because of her seizures. Which response by the nurse would be best?
A person with a history of seizures can drive only during daytime hours.
A person with evidence that the seizures are under medical control can drive.
A person with evidence that seizures occur no more often than every 12 months can drive.
A person with a history of seizures can drive if he carries a medical identification card.
A client tells the nurse that he is unclear about what an aura is. The nurse's response indicates that an aura is
a postictal state of amnesia.
an hallucination that occurs during a seizure.
a symptom that occurs just before a seizure.
a feeling of relaxation as the seizure begins to subside.
Which statement by a client with a seizure disorder taking topiramate (Topamax) indicates the client has understood the nurse's instruction?
"I will take the medicine before going to bed."
"I will drink 6 to 8 glasses of water a day."
"I will eat plenty of fresh fruits."
"I will take the medicine with a meal or snack."
Which clinical manifestation does the nurse assess as a typical reaction to long-term phenytoin sodium (Dilantin) therapy?
Weight gain
Insomnia.
Excessive growth of gum tissue.
Deteriorating eyesight.
Regular oral hygiene is an essential intervention for the client who has had a cerebrovascular accident (CVA). Which of the following nursing measures is inappropriate when providing oral hygiene?
Placing the client on the back with a small pillow under the head.
Keeping portable suctioning equipment at the bedside.
Opening the client's mouth with a padded tongue blade.
Cleaning the client's mouth and teeth with a toothbrush.
A client arrives in the emergency department with an ischemic CVA and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment?
Current medications.
Complete physical and history.
Time of onset of current CVA.
Upcoming surgical procedures.
During the first 24 hours after thrombolytic treatment for an ischemic CVA, the primary goal is to control the client's
pulse.
respirations.
blood pressure.
temperature.
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic CVA?
Cholesterol level.
Pupil size and pupillary response.
Bowel sounds.
Echocardiogram.
What is a priority nursing intervention when suctioning an unconscious client to maintain cerebral perfusion?
Hyperoxygenate before and after suctioning.
Administer analgesics
Provide oral hygiene.
Administer diuretics.
The nursing assessment of a client's functional status before and after a CVA is essential. Why is it so important?
The rehabilitation plan will be guided by it.
Functional status before the CVA will help predict outcomes.
It will help the client recognize his physical limitations.
The client can be expected to regain much of his functioning.
Which of the following techniques does the nurse avoid when changing a client's position in bed if the client has hemiparalysis?
Rolling the client onto her side.
Sliding the client to move her up in bed.
Lifting the client when moving her up in bed
Having the client help lift herself off the bed using a trapeze.
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?
Place the client's feet against a firm footboard.
Reposition the client every 2 hours.
Have the client wear ankle-high tennis shoes at intervals throughout the day.
Massage the client's feet and ankles regularly.
The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm. What position would be inappropriate?
Placing a pillow in the axilla so that the arm is away from the body.
Placing a pillow under the slightly flexed arm so that the hand is higher than the elbow.
Positioning the hands in a slightly pronated position.
Positioning a roll in the hand so that the fingers are barely flexed.
For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?
Speaking loudly.
Using a picture board.
Writing directions so client can read them.
Speaking in short sentences.
The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is inappropriate?
Maintaining an upright position.
Restricting the diet to liquids until swallowing improves.
Introducing foods on the unaffected side of the mouth.
Keeping distractions to a minimum.
Which food-related behaviors would the nurse observe in a client who has had a CVA that has left him with homonymous hemianopia?
Increased preference for foods high in salt.
Eating food on only half of the plate.
Forgetting the names of foods.
Inability to swallow liquids.
The nurse is teaching the client about ways to adapt to a visual disability. Which does the nurse identify as the primary safety precaution to use?
Wear a patch over one eye.
Place personal items on the sighted side.
Lie in bed with the unaffected side toward the door.
Turn the head from side to side when walking.
A client is experiencing mood swings after a CVA and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode?
Sit quietly with the client until the episode is over.
Ignore the behavior.
Attempt to divert the client's attention.
Tell the client that this behavior is unacceptable.
The client who has had a CVA with residual physical handicaps becomes discouraged by his physical appearance. What attitude is best for the nurse to display to help the client overcome his negative self-concept?
Helpfulness and sympathy.
Concern and charity.
Directives and firmness.
Encouragement and patience.
When communicating with a client who has aphasia, which of the following nursing interventions is inappropriate?
Present one thought at a time.
Encourage the client not to write messages.
Speak with normal volume.
Make use of gestures.
What is the expected outcome of thrombolytic drug therapy for CVA?