Hesi Case Study Seizure Disorder – Flashcards

A man sitting across from Alanna starts having a seizure. His entire body is rigid, his arms and legs are contracting and relaxing, and he is making guttural sounds. Alanna yells for the nurse, who immediately comes into the waiting room. 1. Prioritize the nursing actions:

After initial interventions are implemented, the man continues to have a tonic-clonic seizure. 2. What action should the nurse implement next?

After the man's seizure activity stops he is moved to a private room. The client had a 3 minute seizure, has no apparent injuries and is oriented to name, place, and time, but is very lethargic. 3. Which intervention should the nurse implement?

The nurse asks Alanna why she has been referred. Alanna reports that 2 weeks ago her roommate foundher passed out on the floor. Alanna states she could not remember what happened but thought it might be because she had not been eating right. Then, last week Alanna's roommate found her making unusualsounds and noticed that her arms and legs were jerking. At that time she was taken to the emergency de-partment. She has her emergency room records and her past history medical records from her family healthcare provider. 4. To help determine why the seizure activity started, which question should the nurse ask Alanna?

Alanna responds to the nurse's questions, and then tells the nurse that someone has been talking to her about seizures and asked her if she had aura with her seizure. She asks the nurse, "What is an aura?" 5. Which response by the nurse is correct?

The neurologist schedules Alanna for an electroencephalogram (EEG) and a magnetic resonance image (MRI) to help evaluate Alanna's seizure disorder. The nurse discusses the tests with Alanna. 6. Which action should the nurse include in preparing Alanna for the EEG?

Alanna appears overwhelmed with all the information the neurologist discussed with her. She asks the nurse, "I don't understand why the neurologist is ordering an MRI." 7. Which statement by the nurse is the best response?A) "The test will rule out many possible causes of seizures."

The neurologist informs Alanna that no brain tumor, infection, or trauma was found but she did have seizure brain wave activity during the EEG. This brain activity is indicative of Epilepsy. The neurologist prescribes phenytoin (Dilantin), an anticonvulsant, to help prevent the seizure activity. The clinic nurse teaches Alanna about the medication, its side effects, and the need to take it every day. 8. Which statement indicates that Alanna understands the client teaching?

Medication does not ensure that the client will not have seizures. In some instances medication dosage may need to be adjusted or the client may need another medication.The nurse continues to teach Alanna about the newly prescribed anticonvulsant medication. 9. Which instruction should the nurse include in the teaching session?

During the teaching session, Alanna shares with the nurse that she is very scared because she really doesn't remember having the seizure. She states that she had never seen someone with a seizure until the other day in the neurologist's office. Illness has never been part of her life and she doesn't feel sick now. 10. Which response by the nurse is most therapeutic?

Alanna shares that she is worried about being able to have children. She doesn't have a boyfriend right now but someday wants to get married and raise a family. 11. The nurse's response should be based on which scientific rationale?

Education is the key to treating epilepsy. The office nurse teaches Alanna about how to reduce the inci-dence of seizure activity and how to promote safety during a seizure. 12. Which health promotion activity should the nurse discuss with Alanna?

Alanna tells the nurse that she was on her "period" or getting ready to start her "period" both times she had a seizure. She shares with the nurse she is really worried about having a seizure the next time she menstruates. 13. How should the nurse respond?

14. Which statement by Alanna indicates that teaching provided by the nurse has been effective?

Two months after being diagnosed with the seizure disorder, Alanna calls the office and tells the nurse that her job's supervisor has informed her that she is going to be let go because of her seizure disorder. Alanna is very upset and tells the nurse that she has been working at the same department store since she was 18-years-old. 15. Which statement reflects that the nurse understands the legal ramifications of the employer's action?

16. How should the nurse respond?

Alanna, her roommate, and her parents decide to attend an epileptic support group meeting that is held monthly at the local hospital. The topic for tonight is leisure activity and living with epilepsy. A clinical nurse specialist is the guest speaker for the group. One of the group members asks the nurse, "Is it okay for me to swim at the local YMCA?" 17. Which statement is the nurse's best response?

Another member of the group asks if there are any activities that should be avoided. 18. How should the nurse respond?

When the group meeting is over, Alanna privately asks the nurse, "When is the best time to tell a potentialboyfriend I have a seizure disorder?" 19. If the nurse believes in the ethical principle of veracity for the client, how should the nurse respond?

An Emergency OccursThree weeks after the phone call to the office nurse, Alanna is transported to the emergency room by an ambulance, accompanied by her roommate. Her roommate states, "She was watching television and had a seizure. As soon as the first seizure stopped, she started having another seizure, so I called 911." Alan-na is lying on the stretcher with her eyes closed but there is no seizure activity at this time. 20.Which intervention should the nurse implement first?

She has intravenous fluids of 5% Dextrose in Wa-ter (D5W) infusing at 100 ml/hour in the left forearm. The emergency room physician prescribes phenytoin (Dilantin) 25 mg intravenous push. 21. Which action should the nurse implement?

An hour later, Alanna is awake and alert. She does not remember what happened but remembers hearinga buzzing sound. The next thing she remembers is waking up in the emergency room. 22. Which question is most important for the nurse to ask Alanna?

Alanna is admitted to the medical unit and her parents arrive a few minutes later. She is drowsy but arouses easily to verbal stimuli. 23.Which intervention should the nurse implement?

Alanna's mother tells the nurse that neither she nor her father have ever seen Alanna have a seizure. They have read all the information on epilepsy and have talked to Alanna and the neurologist about the seizures but are very worried about their daughter. The mother tells the nurse, "I don't think I would know what to do if I saw her have a seizure." 24. How should the nurse respond?

Alanna's primary nurse realizes that Alanna is of the Jewish faith and wants to provide culturally sensitive nursing care during her hospitalization. 25. Which statement reflects that the nurse is sensitive to Alanna's cultural needs?

Alanna later tells the nurse that she and her family do follow a kosher diet. The next morning, Alanna's parents arrive at the nurses' station with a kosher breakfast for Alanna, which includes a bagel, scrambledeggs, and a glass of orange juice. Alanna has no prescribed dietary restrictions. 26. What action should the nurse take?

Alanna is discharged from the hospital after 2 days. Her Dilantin level is 10.4 mcg/ml after receiving intra-venous Dilantin. Alanna's neurologist is changing Alanna's anticonvulsant from Dilantin to valproic acid (Depakote) to reduce possible side effects and increase her compliance with medication administration. 27. Which action should the nurse include when providing discharge teaching regarding the new medication?

Prior to Alanna's discharge the nurse evaluates the client teaching provided during this hospitalization. 28. When planning care, which client teaching goal is most important when determining Alanna's understand-ing? The client will