ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 37 : Caring for Clients With Central and Peripheral Nervous System Disorders Questions
Question 1 of 5
A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse?
Correct Answer: C
Rationale: When a client begins to convulse, the highest priority is to maintain airway. This can best be accomplished by turning client to side-lying position, which allows saliva and emesis to drain from the mouth. Turning the client also allows the tongue to fall forward opening the airway. More damage can occur if a bite block is inserted after the seizure has begun. Manually restraining extremities is not recommended. Attempting to take blood pressure is not recommended and pulse rate and respirations during the event will not be beneficial. Monitor vital signs during the postictal phase.
Question 2 of 5
The nurse is caring for a client who has a generalized seizure. Which nursing assessment is a priority for detailing the event?
Correct Answer: C
Rationale: Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and the skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.
Question 3 of 5
The nursing instructor gives students an assignment of making a plan of care for a client with Huntington disease. What would be important for the students to include in the teaching portion of the care plan?
Correct Answer: D
Rationale: The nurse demonstrates how to facilitate tasks such as using both hands to hold a drinking glass, using a straw to drink, and wearing slip-on shoes. The teaching portion of the care plan would not include how to exercise, perform household tasks, or take a bath.
Question 4 of 5
The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved?
Correct Answer: C
Rationale: Unless intracranial pressure is resolved, the brain will shift to the lateral side or herniate downward through the foramen magnum. Inflammation occurs from damage to the brain but will reach a maximum. Blood vessels do not dilate as a result of intracranial pressure. Peripheral edema is not a concern.
Question 5 of 5
Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?
Correct Answer: B
Rationale: All of the goals are appropriate, but the most important goal is the long-term goal to remain free of injury if a seizure occurs. Nursing interventions associated can include notifying someone of not feeling well, lowering self to a safe position, protecting head, turning on a side, etc. Also, the client may be at a risk for injury because, once a seizure begins, the client cannot implement self-protective behaviors. An established plan is important in the care of a seizure client. The other options are acceptable goals for nursing care.