Med surg2 Exam 4 Questions and
Answers|Latest Update
While the nurse is transporting a patient on a stretcher to the radiology
department, the patient begins having a tonic-clonic seizure. Which action
should the nurse take
Insert an oral airway during the seizure to maintain a patent airway.
Restrain the patient's arms and legs to prevent injury during the seizure.
Time and observe and record the details of the seizure and postictal state.
Avoid touching the patient to prevent further nervous system stimulation.
Time and observe and record the details of the seizure and postictal state.
Because the diagnosis and treatment of seizures frequently are based on the
description of the seizure, recording the length and details of the seizure is
important. Insertion of an oral airway and restraining the patient during the
seizure are contraindicated. The nurse may need to move the patient to decrease
the risk of injury during the seizure.
A high school teacher who has just been diagnosed with epilepsy after having a
generalized tonic-clonic seizure tells the nurse, "I cannot teach anymore, it will
be too upsetting if I have a seizure at work." Which response by the nurse is best
"You might benefit from some psychologic counseling."
"Epilepsy usually can be well controlled with medications."
,"You will want to contact the Epilepsy Foundation for assistance."
"The Department of Vocational Rehabilitation can help with work retraining."
"Epilepsy usually can be well controlled with medications."
A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the
nurse take when evaluating for adverse effects of the medication
Inspect the oral mucosa.
Listen to the lung sounds.
Auscultate the bowel tones.
Check pupil reaction to light.
Inspect the oral mucosa.
Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung
sounds, or pupil reaction to light.
A patient reports feeling numbness and tingling of the left arm before
experiencing a tonic-clonic seizure. The nurse determines that this history is
consistent with what type of seizure
Focal
Atonic
Absence
Myoclonic
Focal
, The initial symptoms of a focal seizure involve clinical manifestations that are
localized to a particular part of the body or brain. Symptoms of an absence seizure
are staring and a brief loss of consciousness. In an atonic seizure, the patient loses
muscle tone and (typically) falls to the ground. Myoclonic seizures are
characterized by a sudden jerk of the body or extremities.
A 73-year-old patient with Parkinson's disease has a nursing diagnosis of
impaired physical mobility related to bradykinesia. Which action will the nurse
include in the plan of care
Instruct the patient in activities that can be done while lying or sitting.
Suggest that the patient rock from side to side to initiate leg movement.
Have the patient take small steps in a straight line directly in front of the feet.
Teach the patient to keep the feet in contact with the floor and slide them
forward.
Suggest that the patient rock from side to side to initiate leg movement.
Rocking the body from side to side stimulates balance and improves mobility. The
patient will be encouraged to continue exercising because this will maintain
functional abilities. Maintaining a wide base of support will help with balance. The
patient should lift the feet and avoid a shuffling gait.
Answers|Latest Update
While the nurse is transporting a patient on a stretcher to the radiology
department, the patient begins having a tonic-clonic seizure. Which action
should the nurse take
Insert an oral airway during the seizure to maintain a patent airway.
Restrain the patient's arms and legs to prevent injury during the seizure.
Time and observe and record the details of the seizure and postictal state.
Avoid touching the patient to prevent further nervous system stimulation.
Time and observe and record the details of the seizure and postictal state.
Because the diagnosis and treatment of seizures frequently are based on the
description of the seizure, recording the length and details of the seizure is
important. Insertion of an oral airway and restraining the patient during the
seizure are contraindicated. The nurse may need to move the patient to decrease
the risk of injury during the seizure.
A high school teacher who has just been diagnosed with epilepsy after having a
generalized tonic-clonic seizure tells the nurse, "I cannot teach anymore, it will
be too upsetting if I have a seizure at work." Which response by the nurse is best
"You might benefit from some psychologic counseling."
"Epilepsy usually can be well controlled with medications."
,"You will want to contact the Epilepsy Foundation for assistance."
"The Department of Vocational Rehabilitation can help with work retraining."
"Epilepsy usually can be well controlled with medications."
A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the
nurse take when evaluating for adverse effects of the medication
Inspect the oral mucosa.
Listen to the lung sounds.
Auscultate the bowel tones.
Check pupil reaction to light.
Inspect the oral mucosa.
Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung
sounds, or pupil reaction to light.
A patient reports feeling numbness and tingling of the left arm before
experiencing a tonic-clonic seizure. The nurse determines that this history is
consistent with what type of seizure
Focal
Atonic
Absence
Myoclonic
Focal
, The initial symptoms of a focal seizure involve clinical manifestations that are
localized to a particular part of the body or brain. Symptoms of an absence seizure
are staring and a brief loss of consciousness. In an atonic seizure, the patient loses
muscle tone and (typically) falls to the ground. Myoclonic seizures are
characterized by a sudden jerk of the body or extremities.
A 73-year-old patient with Parkinson's disease has a nursing diagnosis of
impaired physical mobility related to bradykinesia. Which action will the nurse
include in the plan of care
Instruct the patient in activities that can be done while lying or sitting.
Suggest that the patient rock from side to side to initiate leg movement.
Have the patient take small steps in a straight line directly in front of the feet.
Teach the patient to keep the feet in contact with the floor and slide them
forward.
Suggest that the patient rock from side to side to initiate leg movement.
Rocking the body from side to side stimulates balance and improves mobility. The
patient will be encouraged to continue exercising because this will maintain
functional abilities. Maintaining a wide base of support will help with balance. The
patient should lift the feet and avoid a shuffling gait.
