NURS 4 exam 5 practice answers

NURS 4 exam 5 practice answers1. B. D. E. Rationale Bite blocks or padded tongue blades should not be used because the client's jaw may clench, causing teeth to break and possibly obstructing the airway. The client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? Select all that apply. 2. A. Absence Rationale A. Absence seizures are more common in children and consist of brief (often just seconds) periods of loss of consciousness and blank staring, as though he or she is daydreaming. B. Myoclonic seizures are characterized by brief jerking or stiffening of the extremities, which may occur singly or in groups. C. Partial seizures are most often seen in adults. D. Tonic seizures are characterized by an abrupt increase in muscle tone, loss of consciousness, and autonomic changes lasting from 30 seconds to several minutes. 3. C. Assess the need for additional support Rationale A. Phenytoin (Dilantin) is administered to prevent the recurrence of seizures, not to treat a seizure already under way. B. Drawing blood is not the priority in this situation. C. Convulsive status epilepticus must be treated promptly and aggressively. After a quick assessment by the nurse, the health care provider must be notified immediately, and intubation by an anesthesiologist, nurse anesthetist, or respiratory therapist may be necessary. D. Starting an IV is not the priority in this situation. 4. D. Positions the client on the side Rationale A. Documenting the length and time of seizures is important, but not while the seizure is occurring. B. Forcing a tongue blade in the mouth can cause damage. C. Restraining the client can cause injury. D. Turning the client on the side during a generalized tonic-clonic or complex partial seizure is indicated because he or she may lose consciousness. 5. B. C. D. Rationale Carbamazepine does not cause alopecia. Divalproex (Depakote) and valproic acid (Depakene) may cause alopecia. 6. B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes Rationale A. This not a medical emergency and does not require immediate attention. B. This client is experiencing status epilepticus, which is a medical emergency and requires immediate intervention.