Olivia McRitchie
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NCLEX (Medical-Surgical) Nursing Test sobre Exemplar 11.2: Seizure Disorders, creado por Olivia McRitchie el 02/10/2018.

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Olivia McRitchie
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Exemplar 11.2: Seizure Disorders

Pregunta 1 de 9

1

Drag and drop the seizure type with the description.

:
-Typically only involves motor portion of brain.
-Manifests as recurrent muscle contractions of face or contralateral part of body.
-If ANS is disrupted, it may also cause tachycardia, flushing, hypotension, or hypertension.
-May have psychological manifestations, such as deja vu, inappropriate fear or anger, abnormal sensations, or hallucinations.
-No alteration in consciousness
-Involves a restricted part of one cerebral hemisphere.

:
-Sudden loss of consciousness preceded by a warning aura.
- Alternating contraction & relaxation of muscles, hyperventilation, eyes rolled back, frothing at the mouth, subsides after 60-90 seconds.
-: Sharp muscle contraction that forces air out of lungs, loss of postural control, rigid muscles, extended arms and legs, jaw clenched, urinary & bowel incontinence, cessation of breathing & cyanosis, fixed & dilated pupils, lasting 15-60 seconds.
-: Unconscious & unresponsive, but regaining conscious gradually; relaxed & breathing quietly; may be confused & disoriented when walking; headache, muscle ache, fatigue; may sleep for several hours; amnesia for duration of & after seizure.

:
-Impaired level of consciousness
-Brief cessation of motor activity
-Blank stare, unresponsiveness,
-Usually 5-10 seconds.
-Can be up to several hundred per day.
-Both hemispheres of brain, as well as deeper structures,

:
-Continual seizure activity w/short periods of calm
-Any type, but usually generalized tonic-clonic
-Danger of hypoxia, acidosis, hypoglycemia, hyperthermia, and exhaustion.

:
-Often proceeded by an aura
-Impaired consciousness lasting for several hours
-Repetitive non purposeful activity, called automatisms
-Amnesia is common after.
-Activation of only a restricted part of one cerebral hemisphere, usually originating in temporal lobe.

Arrastra y suelta para completar el texto.

    Simple partial
    Tonic clonic
    Clonic tonic
    Clonic phase:
    Tonic phase
    Postictal phase
    Absence
    Status epilepticus
    Complex partial

Explicación

Pregunta 2 de 9

1

Which of the following is NOT a reason that a person may have a seizure?

Selecciona una de las siguientes respuestas posibles:

  • Genetic factors

  • Trauma

  • Infection

  • Hypoglycemia

  • Hypotonic dehydration

  • Electrolyte imbalances

  • Endocrine dysfunction

  • Toxins

  • Tumors & lesions

  • Hypertonic dehydration

Explicación

Pregunta 3 de 9

1

Anticonvulsant drugs only work by raising the seizure threshold.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 4 de 9

1

Which of the following is NOT an appropriate intervention for status epilepticus?

Selecciona una de las siguientes respuestas posibles:

  • Maintaining a patent airway w/jaw thrust maneuver & oxygen

  • Establishing an IV line

  • Administering 50% dextrose

  • Administer diazepam, lorazepam, for midazolam IV every 10 minutes until seizure activity stops.

  • Monitor vital signs and circulation

  • Keep suction equipment at bedside

  • Manage thermoregulation

  • Perform neurological assessment

  • Administer carbamazepine and diazepam IV every 15 minutes until seizure activity stops.

Explicación

Pregunta 5 de 9

1

Select the nursing considerations unique to phenytoin.

Selecciona una o más de las siguientes respuestas posibles:

  • Gingival hyperplasia

  • Monitor serum calcium level

  • Administer 2 hours after antacids.

  • Administer with food.

Explicación

Pregunta 6 de 9

1

You have a 23-year-old patient with epilepsy. She is being given primidone to control her seizures. What would you be looking for in this patient?

Selecciona una o más de las siguientes respuestas posibles:

  • Drops in blood pressure, heart rate, and respirations.

  • Blurred or dimmed vision

  • Slurred speech

  • Nystagmus

  • Confusion

  • Increases in blood pressure, heart rate, and respirations

  • Nervousness

  • Dry mouth

Explicación

Pregunta 7 de 9

1

You have a patient brought into the E.D. following a seizure in the department store. She is conscious, but disoriented and sleepy. She reports that one second she had a ringing in her ears and felt "out-of-body" and the next she's on the floor with a 7/10 headache and people around her "freaking out". She reports that this has never happened before.

You believe that she had a tonic-clonic seizure, but you need to get a clearer image. The patient's husband watched the whole episode. Which of the following questions is inappropriate for the information you currently have?

Selecciona una de las siguientes respuestas posibles:

  • "What was your wife doing just before the seizure?"

  • "Were you able to see what part of the body the seizure started in?"

  • "Did she make a loud noise before she fell?"

  • "Can you describe the movements she was making after she fell? Did the location and character change at some point in time?"

  • "Did you notice her head or eyes turn to one side before the seizure started?"

  • "Did she hit her head when she fell?"

  • "Was she foaming or frothing at the mouth?"

  • "Did you notice eyelid fluttering, chewing, lip smacking, or swallowing?"

Explicación

Pregunta 8 de 9

1

You are teaching a group of employees at a department store about what to do if a customer has a seizure. Which of the following statements made by an employee shows that more teaching is needed?

Selecciona una de las siguientes respuestas posibles:

  • "I need to put something in the customer's mouth to prevent tongue biting,"

  • "I will position the customer on his/her side."

  • "I will move any objects that may be around the customer."

Explicación

Pregunta 9 de 9

1

Oxygen should be administered to the seizing patient immediately.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

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