Question

A 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 patients assigned room? (Select all that apply.)

Answer 1

Correct Answers:

Suction Tubing
Oxygen Mask
Side Rail Pad

Rationale :

Suction equipment is essential to prevent aspiration in case of another seizure. Oxygen and side rail padding help maintain airway patency and prevent injury.

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Answer 2

Correct Answers:

Brudzinskis sign

Rationale :

Brudzinski’s sign occurs when passive neck flexion causes involuntary hip and knee flexion, indicating meningeal irritation.

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Answer 3

Correct Answers:

Plantar flexion of the legs

Rationale :

Decorticate posturing (flexor posturing) involves arms flexed toward the chest, legs extended, and plantar flexion of the feet. It indicates severe brain injury, but is less severe than decerebrate posturing, which involves arm extension.

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Answer 4

Correct Answers:

Inquire about urinary tract problems.

Rationale :

Bladder dysfunction (urgency, frequency, retention) is a common early sign of MS.

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Answer 5

Correct Answers:

Change in mood or attention level

Rationale :

Subtle changes in mental status (irritability, confusion) often precede more severe ICP symptoms. A rising systolic BP and irregular respirations are later signs of ICP.

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Answer 6

Correct Answers:

Turn the clients head to the side.

Rationale :

Turning the client’s head helps maintain an open airway and prevents aspiration.

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Answer 7

Correct Answers:

Paraplegia

Rationale :

A T2-T3 injury results in paraplegia, or loss of movement in the lower extremities. Quadriplegia occurs with cervical injuries, while hemiplegia is often seen in strokes.

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Answer 8

Correct Answers:

Inspect the oral mucosa

Rationale :

Phenytoin commonly causes gingival hyperplasia (overgrowth of gum tissue), requiring regular oral hygiene. Checking pupils or lung sounds does not assess for this specific side effect.

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Answer 9

Correct Answers:

Administer lorazepam (Ativan) 4 mg 'V.

Rationale :

IV benzodiazepines (lorazepam) are first-line treatment for status epilepticus to stop the seizure. Phenytoin is used for long-term seizure control but is not fast-acting.

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Answer 10

Correct Answers:

"Epilepsy usually can be well controlled with medications."

Rationale :

Most cases of epilepsy are controlled with medication, allowing individuals to work and live normally. Offering psychological counseling is helpful but does not directly address the patient's fear about work.

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RN ATI Advanced Medsurg Cohort 4 Exam 2

No.

1 : A 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 patients assigned room? (Select all that apply.)

2 : A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?

3 : An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

4 : What action should the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)?

5 : When assessing the client with meningitis, the nurse looks for which manifestation as a frequent first sign of increased intracranial pressure?

6 : A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

7 : A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?

8 : A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication?

9 : Which prescribed intervention should the emergency department nurse implement first for a patient who is experiencing continuous tonic-clonic seizures?

10 : A high school teacher who has been diagnosed with epilepsy after having a generalized tonic- clonic seizure tells the nurse, "l cannot teach anymore. It will be too upsetting if I have a seizure at work." How should the nurse respond to specifically address the patient's concern?

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