HESI Case Studies–Medical/Surgical-Seizure Disorder (Alanna Milstein) – Flashcards
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1. Prioritize the nursing actions in order from first action through last action
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1. Safely move the client to the floor 2. Push the furniture away from the client 3. Remove people from the waiting room 4. Assess the client's blood pressure
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2. What action should the nurse implement next?
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Note the time, duration, and type of seizure
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3. Which intervention should the nurse implement?
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Turn the client to the side, and allow him to sleep
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4. Which of the medical history question(s) should the nurse ask Alanna to determine why the seizure activity started? (Select all)
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-"Have you ever had any type of head injury?" -"Do you have a history of drinking alcohol?"
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5. Which response by the nurse is correct?
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"It is a visual or auditory warning that the seizure is about to start."
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6. Which action should the nurse include in preparing Alanna for the EEG?
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Instruct the client to refrain from consuming caffeine prior to the EEG
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7. Which statement by the nurse is the best response?
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"The test will rule out many possible causes of seizures"
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8. Which statement indicates that Alanna understands the client teaching?
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"I must brush and floss my teeth after every meal."
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9. Which instruction should the nurse include in the teaching session?
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Avoid hazardous tasks until the drug has been regulated
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10. Which response by the nurse is most therapeutic?
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"This is all new to you, and you must be frightened. Let's talk for a while."
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11. The nurse's response should be based on which scientific rationale?
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Epilepsy does not prevent women from having children
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12. Which health promotion activity should the nurse discuss with Alanna?
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Learn to identify seizure triggers
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13. How should the nurse respond?
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"Your menstrual cycle can cause seizure activity due to hormone levels."
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14. Which statement by Alanna indicates that teaching provided by the nurse has been effective?
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"I will carry a Medic Alert band at all times."
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15. Which statement reflects that the nurse understands the legal ramifications of the employer's action?
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"According to the Americans with Disabilities Act, your employer cannot terminate you."
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16. How should the nurse respond?
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"You need to contact the Department of Transportation to find out the state laws."
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17. Which statement is the nurse's best response?
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"Someone who knows what to do if you have a seizure should be with you."
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18. How should the nurse respond?
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"It really depends on how well your epilepsy is controlled."
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19. If the nurse believes in the ethical principle of veracity for the client, how should the nurse respond?
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"You should tell him the truth on the first date so he will know."
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20. Which intervention should the nurse implement first?
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Ensure suction equipment is at the bedside
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21. Which action should the nurse implement?
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Dilute the medication and flush the tubing before and after with normal saline
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22. Which question is most important for the nurse to ask Alanna?
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"Have you been taking your medication regularly?"
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23. Which intervention should the nurse implement?
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Pad and elevate the side rails of Alanna's bed
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24. How should the nurse respond?
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"The most important thing is to keep her from injuring herself."
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25. Which statement reflects that the nurse is sensitive to Alanna's cultural needs?
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"Tell me about the type of Jewish teachings you practice."
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26. What action should the nurse take?
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Return the tray provided by the hospital and ask the parents if they would like to take the meal they provided to Alanna's room
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27. Which action should the nurse include when providing discharge teaching regarding the new medication?
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Discuss with the client the importance of having liver function tests while on this medication
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28. Which client teaching goal is most important to determine Alanna's understanding?
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Describe five strategies to prevent seizure activity
