Chapter 23: Care of Patients with Disorders of the Brain |DeWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition

MULTIPLE CHOICE 1. The nurse is caring for a patient who recently suffered a cerebrovascular accident (CVA). Family members ask the nurse why their father had a seizure. Which response is best for the nurse to make? a. “The seizure was most likely caused by brain cells being deprived of oxygen due to a blood clot in the brain.” b. “The stroke generated a toxin that excites the brain cells.” c. “The stroke causes an alteration in the cells adjacent to the blood clot.” d. “The stroke causes an increase in the depolarization of the brain cells due to the clot formation.” ANS: A Thrombi from a CVA can occlude vessels, cutting off oxygen supply to cells of the brain and causing a seizure. PTS:1 DIF: Cognitive Level: Comprehension REF: 524 OBJ:2 (theory) TOP: Seizure: Etiology KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse is providing teaching to a patient newly diagnosed with simple partial seizure disorder. Which statement by the nurse is most accurate? a. “Your seizures will typically only affect one side of your body.” b. “Simple partial seizures may result in an alteration of consciousness.” c. “The simple partial seizure may cause motor impairment to begin in all of your extremities.” d. “Simple partial seizures are not treatable.” ANS: A Simple partial seizures only involve one side of the brain and one side of the body. Complex partial seizures may or may not result in an alteration in level of consciousness. Generalized seizures affect both sides of the body. Simple partial seizures may respond to treatment. PTS:1 DIF: Cognitive Level: Application REF: 525 OBJ:1 (theory) TOP: Simple Partial Seizures KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse is caring for an anxious 20-year-old college student who just suffered his first seizure in his dorm room. The patient asks the nurse if he is now an epileptic. What is the nurse’s best response? a. “No. All other causes of seizure activity must be ruled out before the diagnosis of epilepsy is made.” b. “Yes, but you may never have another seizure since it has just now manifested itself.” c. “No, but you should see a physician to get a prescription for a preventative antispasmodic.” d. “Yes. All seizures are considered to be epilepsy.” ANS: A Epilepsy diagnosis is made after all other causes of seizure activity have proven negative. All seizures are not considered to be epilepsy. PTS:1 DIF: Cognitive Level: Comprehension REF: 525 OBJ:1 (clinical) TOP: Seizures vs. Epilepsy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 4. The nurse instructs a person taking phenytoin (Dilantin) that periodic blood tests will be necessary. The nurse explains that the laboratory checks will monitor for which potential medication-induced change? a. Potassium depletion b. Liver damage c. Increasing creatinine d. Increasing sedimentation rates