NUR 104 - EXAM 2 LATEST
A patient has been taking phenytoin (Dilantin) for 2 years. Which action
will the nurse take when evaluating for
adverse effects of the medication?
a. Inspect the oral mucosa.
b. Listen to the lung sounds.
c. Auscultate the bowel tones.
d. Check pupil reaction to light. - ANSWERS-a. 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?
a. Focal
b. Atonic
c. Absence
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, NUR 104 - EXAM 2 LATEST
d. Myoclonic - ANSWERS-a. 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.
The nurse observes a patient ambulating in the hospital hall when the
patient's arms and legs suddenly jerk and the patient falls to the floor.
The nurse will first
a. assess the patient for a possible head injury.
b. give the scheduled dose of divalproex (Depakote).
c. document the timing and description of the seizure.
d. notify the patient's health care provider about the seizure. -
ANSWERS-a. assess the patient for a possible head injury.
The patient who has had a myoclonic seizure and fall is at risk for head
injury and should first be evaluated and treated for this possible
complication. Documentation of the seizure, notification of the seizure,
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PAGE
2
, NUR 104 - EXAM 2 LATEST
and administration of antiseizure medications are also appropriate
actions, but the initial action should be assessment for injury.
Which prescribed intervention will the nurse implement first for a
patient in the emergency department who is
experiencing continuous tonic-clonic seizures?
a. Give phenytoin (Dilantin) 100 mg IV.
b. Monitor level of consciousness (LOC).
c. Obtain computed tomography (CT) scan.
d. Administer lorazepam (Ativan) 4 mg IV. - ANSWERS-d. Administer
lorazepam (Ativan) 4 mg IV.
To prevent ongoing seizures, the nurse should administer rapidly acting
antiseizure medications such as the
benzodiazepines. A CT scan is appropriate, but prevention of any
seizure activity during the CT scan is necessary.
Phenytoin will also be administered, but it is not rapidly acting. Patients
who are experiencing tonic-clonic seizures are nonresponsive, although
the nurse should assess LOC after the seizure.
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PAGE
3
, NUR 104 - EXAM 2 LATEST
The home health registered nurse (RN) is planning care for a patient
with a seizure disorder related to a recent head injury. Which nursing
action can be delegated to a licensed practical/vocational nurse
(LPN/LVN)?
a. Make referrals to appropriate community agencies.
b. Place medications in the home medication organizer.
c. Teach the patient and family how to manage seizures.
d. Assess for use of medications that may precipitate seizures. -
ANSWERS-b. Place medications in the home medication organizer.
LPN/LVN education includes administration of medications. The other
activities require RN education and scope of
practice.
A 27-year-old patient who has been treated for status epilepticus in the
emergency department will be transferred to the medical nursing unit.
Which equipment should the nurse have available in the patient's
assigned room (select all that apply)?
a. Side-rail pads
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PAGE
4
A patient has been taking phenytoin (Dilantin) for 2 years. Which action
will the nurse take when evaluating for
adverse effects of the medication?
a. Inspect the oral mucosa.
b. Listen to the lung sounds.
c. Auscultate the bowel tones.
d. Check pupil reaction to light. - ANSWERS-a. 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?
a. Focal
b. Atonic
c. Absence
END OF
PAGE
1
, NUR 104 - EXAM 2 LATEST
d. Myoclonic - ANSWERS-a. 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.
The nurse observes a patient ambulating in the hospital hall when the
patient's arms and legs suddenly jerk and the patient falls to the floor.
The nurse will first
a. assess the patient for a possible head injury.
b. give the scheduled dose of divalproex (Depakote).
c. document the timing and description of the seizure.
d. notify the patient's health care provider about the seizure. -
ANSWERS-a. assess the patient for a possible head injury.
The patient who has had a myoclonic seizure and fall is at risk for head
injury and should first be evaluated and treated for this possible
complication. Documentation of the seizure, notification of the seizure,
END OF
PAGE
2
, NUR 104 - EXAM 2 LATEST
and administration of antiseizure medications are also appropriate
actions, but the initial action should be assessment for injury.
Which prescribed intervention will the nurse implement first for a
patient in the emergency department who is
experiencing continuous tonic-clonic seizures?
a. Give phenytoin (Dilantin) 100 mg IV.
b. Monitor level of consciousness (LOC).
c. Obtain computed tomography (CT) scan.
d. Administer lorazepam (Ativan) 4 mg IV. - ANSWERS-d. Administer
lorazepam (Ativan) 4 mg IV.
To prevent ongoing seizures, the nurse should administer rapidly acting
antiseizure medications such as the
benzodiazepines. A CT scan is appropriate, but prevention of any
seizure activity during the CT scan is necessary.
Phenytoin will also be administered, but it is not rapidly acting. Patients
who are experiencing tonic-clonic seizures are nonresponsive, although
the nurse should assess LOC after the seizure.
END OF
PAGE
3
, NUR 104 - EXAM 2 LATEST
The home health registered nurse (RN) is planning care for a patient
with a seizure disorder related to a recent head injury. Which nursing
action can be delegated to a licensed practical/vocational nurse
(LPN/LVN)?
a. Make referrals to appropriate community agencies.
b. Place medications in the home medication organizer.
c. Teach the patient and family how to manage seizures.
d. Assess for use of medications that may precipitate seizures. -
ANSWERS-b. Place medications in the home medication organizer.
LPN/LVN education includes administration of medications. The other
activities require RN education and scope of
practice.
A 27-year-old patient who has been treated for status epilepticus in the
emergency department will be transferred to the medical nursing unit.
Which equipment should the nurse have available in the patient's
assigned room (select all that apply)?
a. Side-rail pads
END OF
PAGE
4
