NU 311 Clinical Nursing Skills Exam 1 South Alabama
Questions With Complete Solutions
- Seizure Precautions & (generalized vs. partial seizure)** & 3
phases to a seizure & status epilepticcus Correct Answer a.-
Seizures are sudden, abnormal, electrical discharges in the brain
causing alterations in behavior, sensation, or consciousness.
Protect the patient, but avoid restraining & forcing something in
the mouth during the seizure. Don't leave the patient alone; call
for help. Remember, dignity.
b.-(Additional- Observe seizure characteristics and duration
c.-Medicate as indicated)
d.-Seizures that appear to begin everywhere in the brain at once
are classified as generalized seizures, whereas seizures
beginning in one location of the brain are classified as partial
seizures. There are three phases to a seizure:
e. STAGES-
•Aura—the start of a partial seizure. If the aura is the only phase
a patient experiences, the patient has had a simple partial
seizure. If the seizure spreads and affects consciousness, it is a
complex partial seizure. If the seizure spreads to the rest of the
brain, it becomes a generalized seizure.
•Ictus—meaning attack. Ictus is another word for the physical
seizure involving a series of muscle contractions, called tonic
and clonic contractions.
•Postictal —meaning after the attack. Postictal refers to the
aftereffects of a seizure (e.g., arm numbness, altered
consciousness, partial paralysis).
f.• Status epilepticcus involves 5 minutes or more of either
continuous clinical or electrographic (shown on an
electroencephalogram [EEG]) seizure activity or recurrent
,seizure activity without recovery between seizures. It is a
medical emergency. Status epilepticus can be convulsive
(rhythmic jerking of)
-Centers for Disease Control and Prevention Isolation
Guidelines
Standard Precautions (Tier One) for Use With All Patients
Cough etiquette (Box 9.2) Correct Answer a. Standard
precautions apply to blood, blood products, all body fluids,
secretions, excretions (except sweat), non-intact skin, and
mucous membranes.
b. Perform hand hygiene before, after, and between direct
contact with patients. (Examples of between-contact activities
are cleaning hands after a patient care activity, moving to a non-
patient care activity, and cleaning hands again before returning
to perform patient contact.)
c. Perform hand hygiene after contact with blood, body fluids,
mucous membranes, nonintact skin, secretions, excretions, or
wound dressings; after contact with inanimate surfaces or
articles in a patient room; and immediately after gloves are
removed.
d. When hands are visibly soiled or contaminated with blood or
body fluids, wash them with either a non-antimicrobial soap or
an antimicrobial soap and water.
e. When hands are not visibly soiled or contaminated with blood
or body fluids, use an alcohol-based hand rub to perform hand
hygiene.
f. Wash hands with non-antimicrobial soap and water if contact
with spores (e.g., Clostridium difficile) is likely to have
occurred.
,g. Do not wear artificial fingernails or extenders if duties include
direct contact with patients at high risk for infection and
associated adverse outcomes.
h. Wear gloves when touching blood, body fluids, secretions,
excretions, non-intact skin, mucous membranes, or
contaminated items or surfaces is likely. Remove gloves and
perform hand hygiene between patient care encounters and when
going from a contaminated to a clean body site.
i. Wear personal protective equipment (PPE) when the
anticipated patient interaction indicates that contact with blood
or body fluids may occur.
j. A private room is unnecessary unless the patient's hygiene is
unacceptable (e.g., unconfined secretions, excretions, or wound
drainage).
k. Discard all
-Droplet precautions cont... (plus standard precautions) Correct
Answer a. Visitors- Report to Nurses station before entering
room
b. Private room- cohorting possible
c. Masks- wear mask within 3 ft. of patient
d. Essential movement/transport only
e. Mask on patient during transport
-Other source of fire that poses a risk in a health care setting?
Correct Answer Although smoking is not allowed in health
care facilities, smoking-related fires still pose a significant risk
because of unauthorized smoking in beds or bathrooms. In the
home setting, oxygen-related fires are a risk for patients
requiring continuous oxygen therapy.
, -Biomedical devices must have a safety inspection sticker with
an expiration date, and all electrical equipment should have a
three-prong plug for grounding.
-Hospital engineers should inspect any electrical devices a
patient brings to the hospital; discourage patients from bringing
nonessential devices.
-If a fire occurs, health care personnel report the exact location
of the fire, contain it, and extinguish it only if it is safe and
possible. All personnel are then mobilized to evacuate patients if
needed.
-Most agencies have fire doors that are held open by magnets
and close automatically when a fire alarm sounds. Fire doors
should never be blocked.
-Chemicals in many medications, anesthetic gases, cleaning
solutions, and disinfectants are potentially toxic. They injure the
body after skin or mucous membrane contact, ingestion, or
vapor inhalation.
-A Safety Data Sheet (SDS) form contains information about the
properties of the particular chemical and information for
handling the substance in a safe manner.
-Seizure Precautions (rolling patient on side)** & status
epilepticcus guidelines con Correct Answer a.• Traditionally
patients who have a seizure are immediately placed in the side-
lying position to prevent aspiration of oral secretions. This is
still a standard of practice. However, the patient should be rolled
gently into this position and only if possible without injuring any
body part. Refer to your agency policy for positioning
guidelines.
b.• The current practice guidelines for patients with status
epilepticus include the following:
Questions With Complete Solutions
- Seizure Precautions & (generalized vs. partial seizure)** & 3
phases to a seizure & status epilepticcus Correct Answer a.-
Seizures are sudden, abnormal, electrical discharges in the brain
causing alterations in behavior, sensation, or consciousness.
Protect the patient, but avoid restraining & forcing something in
the mouth during the seizure. Don't leave the patient alone; call
for help. Remember, dignity.
b.-(Additional- Observe seizure characteristics and duration
c.-Medicate as indicated)
d.-Seizures that appear to begin everywhere in the brain at once
are classified as generalized seizures, whereas seizures
beginning in one location of the brain are classified as partial
seizures. There are three phases to a seizure:
e. STAGES-
•Aura—the start of a partial seizure. If the aura is the only phase
a patient experiences, the patient has had a simple partial
seizure. If the seizure spreads and affects consciousness, it is a
complex partial seizure. If the seizure spreads to the rest of the
brain, it becomes a generalized seizure.
•Ictus—meaning attack. Ictus is another word for the physical
seizure involving a series of muscle contractions, called tonic
and clonic contractions.
•Postictal —meaning after the attack. Postictal refers to the
aftereffects of a seizure (e.g., arm numbness, altered
consciousness, partial paralysis).
f.• Status epilepticcus involves 5 minutes or more of either
continuous clinical or electrographic (shown on an
electroencephalogram [EEG]) seizure activity or recurrent
,seizure activity without recovery between seizures. It is a
medical emergency. Status epilepticus can be convulsive
(rhythmic jerking of)
-Centers for Disease Control and Prevention Isolation
Guidelines
Standard Precautions (Tier One) for Use With All Patients
Cough etiquette (Box 9.2) Correct Answer a. Standard
precautions apply to blood, blood products, all body fluids,
secretions, excretions (except sweat), non-intact skin, and
mucous membranes.
b. Perform hand hygiene before, after, and between direct
contact with patients. (Examples of between-contact activities
are cleaning hands after a patient care activity, moving to a non-
patient care activity, and cleaning hands again before returning
to perform patient contact.)
c. Perform hand hygiene after contact with blood, body fluids,
mucous membranes, nonintact skin, secretions, excretions, or
wound dressings; after contact with inanimate surfaces or
articles in a patient room; and immediately after gloves are
removed.
d. When hands are visibly soiled or contaminated with blood or
body fluids, wash them with either a non-antimicrobial soap or
an antimicrobial soap and water.
e. When hands are not visibly soiled or contaminated with blood
or body fluids, use an alcohol-based hand rub to perform hand
hygiene.
f. Wash hands with non-antimicrobial soap and water if contact
with spores (e.g., Clostridium difficile) is likely to have
occurred.
,g. Do not wear artificial fingernails or extenders if duties include
direct contact with patients at high risk for infection and
associated adverse outcomes.
h. Wear gloves when touching blood, body fluids, secretions,
excretions, non-intact skin, mucous membranes, or
contaminated items or surfaces is likely. Remove gloves and
perform hand hygiene between patient care encounters and when
going from a contaminated to a clean body site.
i. Wear personal protective equipment (PPE) when the
anticipated patient interaction indicates that contact with blood
or body fluids may occur.
j. A private room is unnecessary unless the patient's hygiene is
unacceptable (e.g., unconfined secretions, excretions, or wound
drainage).
k. Discard all
-Droplet precautions cont... (plus standard precautions) Correct
Answer a. Visitors- Report to Nurses station before entering
room
b. Private room- cohorting possible
c. Masks- wear mask within 3 ft. of patient
d. Essential movement/transport only
e. Mask on patient during transport
-Other source of fire that poses a risk in a health care setting?
Correct Answer Although smoking is not allowed in health
care facilities, smoking-related fires still pose a significant risk
because of unauthorized smoking in beds or bathrooms. In the
home setting, oxygen-related fires are a risk for patients
requiring continuous oxygen therapy.
, -Biomedical devices must have a safety inspection sticker with
an expiration date, and all electrical equipment should have a
three-prong plug for grounding.
-Hospital engineers should inspect any electrical devices a
patient brings to the hospital; discourage patients from bringing
nonessential devices.
-If a fire occurs, health care personnel report the exact location
of the fire, contain it, and extinguish it only if it is safe and
possible. All personnel are then mobilized to evacuate patients if
needed.
-Most agencies have fire doors that are held open by magnets
and close automatically when a fire alarm sounds. Fire doors
should never be blocked.
-Chemicals in many medications, anesthetic gases, cleaning
solutions, and disinfectants are potentially toxic. They injure the
body after skin or mucous membrane contact, ingestion, or
vapor inhalation.
-A Safety Data Sheet (SDS) form contains information about the
properties of the particular chemical and information for
handling the substance in a safe manner.
-Seizure Precautions (rolling patient on side)** & status
epilepticcus guidelines con Correct Answer a.• Traditionally
patients who have a seizure are immediately placed in the side-
lying position to prevent aspiration of oral secretions. This is
still a standard of practice. However, the patient should be rolled
gently into this position and only if possible without injuring any
body part. Refer to your agency policy for positioning
guidelines.
b.• The current practice guidelines for patients with status
epilepticus include the following:
