A nurse is caring for a child who is experiencing a seizure. which of the following actions

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1) A 2 year old is to be admitted in the pediatric unit. He is diagnosed with febrile seizures. In preparing for his admission, which of the following is the most important nursing action?

1. Order a stat admission CBC.
2. Place a urine collection bag and specimen cup at the bedside.
3. Place a cooling mattress on his bed
4. Pad the side rails of his bed.

2) A client taking Dilantin (phenytoin) for grand mal seizures is preparing for discharge. Which information should be included in the client’s discharge care plan?

1. The medication can cause dental staining.
2. The client will need to avoid a high-carbohydrate diet.
3. The client will need a regularly scheduled CBC.
4. The medication can cause problems with drowsiness.

3) While working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of these nursing actions will you implement first if the patient has a seizure?

1. Place the patient on a non-rebreather mask will the oxygen at 15 L/minute.
2. Administer lorazepam (Ativan) 1 mg IV.
3. Turn the patient to the side and protect airway.
4. Assess level of consciousness during and immediately after the seizure.

4) Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed?

1. In 30 to 45 seconds
2. In 10 to 15 minutes
3. In 30 to 45 minutes
4. In 1 to 2 hours

5) A nursing student is teaching a patient and family about epilepsy prior to the patient’s discharge. For which statement should you intervene?

1. “You should avoid consumption of all forms of alcohol.”
2. “Wear you medical alert bracelet at all times.”
3. “Protect your loved one’s airway during a seizure.”
4. “It’s OK to take over-the-counter medications.”

6) A 22 year old client suffered from his first tonic-clonic seizure. Upon awakening the client asks the nurse, “What caused me to have a seizure? Which of the following would the nurse include in the primary cause of tonic clonic seizures in adults more the 20 years?

1. Electrolyte imbalance
2. Head trauma
3. Epilepsy
4. Congenital defect

7) Seizures may be caused by but not limited to

1. colds, strep throat, flu
2. infection, injury, lack of sleep
3. fever, trauma, infections, unknown
4. allergies, ear infections, enuresis
5. all of the above

8) A male client is having a tonic-clonic seizures. What should the nurse do first?

1. Elevate the head of the bed.
2. Restrain the client’s arms and legs.
3. Place a tongue blade in the client’s mouth.
4. Take measures to prevent injury.

9) Seizures may be identified by

1. jerking movements over entire body
2. staring
3. loss of awareness
4. arm or leg jerking
5. all of the above

10) A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising? (Choose all that apply).

1. Document the onset time, nature of seizure activity, and postictal behaviors for all seizures.
2. Administer phenytoin (Dilantin) 200 mg PO daily.
3. Teach patient about the need for good oral hygiene.
4. Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.

11) A neurological consult has been ordered for a pediatric client with suspected petit mal seizures. The client with petit mal seizures can be expected to have:

1. Short, abrupt muscle contraction
2. Quick, bilateral severe jerking movements
3. Abrupt loss of muscle tone
4. A brief lapse in consciousness

12) Nurse Becky is caring for client who begins to experience seizure while in bed. Which action should the nurse implement to prevent aspiration?

1. Position the client on the side with head flexed forward
2. Elevate the head
3. Use tongue depressor between teeth
4. Loosen restrictive clothing

13) Which of the following findings in a 2-year-old child assists in identifying the cause of a grand mal seizure?

1. Fever
2. Crackles in the lungs
3. Abdominal tenderness
4. Cardiac dysrhythmia

14) The physician has ordered Dilantin (phenytoin) for a client with generalized seizures. When planning the client’s care, the nurse should:

1. Maintain strict intake and output
2. Check the pulse before giving the medication
3. Administer the medication 30 minutes before meals
4. Provide oral hygiene and gum care every shift

15) When a pregnant woman goes into a convulsive seizure, the MOST immediate action of the nurse to ensure safety of the patient is:

1. Apply restraint so that the patient will not fall out of bed
2. Put a mouth gag so that the patient will not bite her tongue and the tongue will not fall back
3. Position the mother on her side to allow the secretions to drain from her mouth and prevent aspiration
4. Check if the woman is also having a precipitate labor

16) A 36-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus?

1. PO phenytoin and carbamazepine
2. IV lorazepam (Ativan)
3. IV carbamazepam
4. IV magnesium sulfate

17) The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?

1. Document the seizure.
2. Perform neurologic checks.
3. Take the patient’s vital signs.
4. Restrain the patient for protection.

18) Seizures occur in approximately what percentage of children

1. 1-3%
2. 3-5%
3. 5-8%
4. 8-12%

19) John suddenly experiences a seizure, and Nurse Gina notice that John exhibits uncontrollable jerking movements. Nurse Gina documents that John experienced which type of seizure?

1. Tonic seizure
2. Absence seizure
3. Myoclonic seizure
4. Clonic seizure

20) A patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the outpatient clinic. Which information obtained during his chart review and assessment will be of greatest concern?

1. The gums appear enlarged and inflamed.
2. The white blood cell count is 2300/mm3.
3. Patient occasionally forgets to take the phenytoin until after lunch.
4. Patient wants to renew his driver’s license in the next month.

21) The nurse answers a call bell and finds a frightened mother whose child, the patient, is having a seizure. Which of these actions should the nurse take?

1. The nurse should insert a padded tongue blade in the patient’s mouth to prevent the child from swallowing or choking on his tongue.
2. The nurse should help the mother restrain the child to prevent him from injuring himself.
3. The nurse should call the operator to page for seizure assistance.
4. The nurse should clear the area and position the client safely.

22) Treatment plan for seizures includes

1. clear area around child
2. restrain jerking movements to prevent injury
3. observe and document activity
   call 911 if seizure activity lasts longer than 5 minutes
4. A&C
5. B&C

23) Mr. Jessie Ray, a newly admitted patient, has a seizure disorder which is being treated with medication. Which of the following drugs would the nurse question if ordered for him?

1. Phenobarbitol, 150 mg hs
2. Amitriptylene (Elavil), 10 mg QID.
3. Valproic acid (Depakote), 150 mg BID
4. Phenytoin (Dilantin), 100 mg TID

24) The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse?

1. “Do not worry. Epilepsy can be treated with medications.”
2. “The seizure may or may not mean your child has epilepsy.”
3. “Since this was the first convulsion, it may not happen again.”
4. “Long term treatment will prevent future seizures.”

25) A client with eclampsia begins to experience a seizure. Which of the following would the nurse in charge do first?

1. Pad the side rails
2. Place a pillow under the left buttock
3. Insert a padded tongue blade into the mouth
4. Maintain a patent airway

26) Following a generalized seizure, the nurse can expect the client to:

1. Be unable to move the extremities
2. Be drowsy and prone to sleep
3. Remember events before the seizure
4. Have a drop in blood pressure

27) A hospitalized client had a tonic-clonic seizure while walking in the hall. During the seizure the nurse priority should be:

1. Hold the clients arms and leg firmly
2. Place the client immediately to soft surface
3. Protects the client’s head from injury
4. Attempt to insert a tongue depressor between the client’s teeth

28) You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN?

1. Complete admission assessment.
2. Set up oxygen and suction equipment.
3. Place a padded tongue blade at bedside.
4. Pad the side rails before patient arrives.

29) A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?

1. Place the child in the nearest bed
2. Administer IV medication to slow down the seizure
3. Place a padded tongue blade in the child’s mouth
4. Remove the child’s toys from the immediate area

30) The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated?

1. Loosening restrictive clothing
2. Restraining the client’s limbs
3. Removing the pillow and raising padded side rails
4. Positioning the client to side, if possible, with the head flexed forward

1. D. Pad the side rails of his bed. Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. A cooling blanket must be ordered by the physician and is usually not used unless other methods for the reduction of fever have not been successful. The child has a diagnosis of febrile seizures. Precautions to prevent injury and promote safety should take precedence.
2.  C. The client will need a regularly scheduled CBC. Adverse side effects of Dilantin include agranulocytosis and aplastic anemia; therefore, the client will need frequent CBCs. Answer A is incorrect because the medication does not cause dental staining. Answer B is incorrect because the medication does not interfere with the metabolism of carbohydrates. Answer D is incorrect because the medication does not cause drowsiness.
3. C. Turn the patient to the side and protect airway. The priority action during a generalized tonic-clonic seizure is to protect the airway. Administration of lorazepam should be the next action, since it will act rapidly to control the seizure. Although oxygen may be useful during the postictal phase, the hypoxemia during tonic-clonic seizures is caused by apnea. Checking the level of consciousness is not appropriate during the seizure, because generalized tonic-clonic seizures are associated with a loss of consciousness. Focus: Prioritization
4. B. In 10 to 15 minutes . When used to treat status epilepticus, diazepam may be given every 10 to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4 hours, if necessary, but the total dose shouldn’t exceed 100 mg in 24 hours. The nurse must not administer I.V. diazepam faster than 5 mg/minute. Therefore, the dose can’t be repeated in 30 to 45 seconds because the first dose wouldn’t have been administered completely by that time. Waiting longer than 15 minutes to repeat the dose would increase the client’s risk of complications associated with status epilepticus.
5. D. “It’s OK to take over-the-counter medications.” A patient with a seizure disorder should not take over-the-counter medications without consulting with the physician first. The other three statements are appropriate teaching points for patients with seizures disorders and their families. Focus: Delegation/supervision
6. B. Head trauma . Trauma is one of the primary cause of brain damage and seizure activity in adults. Other common causes of seizure activity in adults include neoplasms, withdrawal from drugs and alcohol, and vascular disease.
7. C. fever, trauma, infections, unknown 
8. D. Take measures to prevent injury. Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the client’s condition or safety. Restraining the client’s arms and legs could cause injury. Placing a tongue blade or other object in the client’s mouth could damage the teeth.
9.  E. all of the above
10. B. Administer phenytoin (Dilantin) 200 mg PO daily. Administration of medications is included in LPN education and scope of practice. Collection of data about the seizure activity may be accomplished by an LPN/LVN who observes initial seizure activity. An LPN/LVN would know to call the supervising RN immediately if a patient started to seize. Documentation of the seizure, patient teaching, and planning of care are complex activities that require RN level education and scope of practice. Focus: Delegation
11. D. A brief lapse in consciousness . Absence seizures, formerly known as petit mal seizures, are characterized by a brief lapse in consciousness accompanied by rapid eye blinking, lip smacking, and minor myoclonus of the upper extremities. Answer A refers to myoclonic seizure; therefore, it is incorrect. Answer B refers to tonic clonic, formerly known as grand mal, seizures; therefore, it is incorrect. Answer C refers to atonic seizures; therefore, it is incorrect.
12. A. Position the client on the side with head flexed forward . Positioning the client on one side with head flexed forward allows the tongue to fall forward and facilitates drainage secretions therefore prevents aspiration.
13. A. Fever 
14. D. Provide oral hygiene and gum care every shift . Gingival hyperplasia is a side effect of Dilantin; therefore, the nurse should provide oral hygiene and gum care every shift. Answers A, B, and C do not apply to the medication; therefore, they are incorrect.
15.  C. Position the mother on her side to allow the secretions to drain from her mouth and prevent aspiration. Positioning the mother on her side will allow the secretions that may accumulate in her mouth to drain by gravity thus preventing aspiration pneumonia. Putting a mouth gag is not safe since during the convulsive seizure the jaw will immediately lock. The mother may go into labor also during the seizure but the immediate concern of the nurse is the safety of the baby. After the seizure, check the perineum for signs of precipitate labor.
16. B. IV lorazepam (Ativan). IV Lorazepam (Ativan) is the drug of choice for status epilepticus. Tegretol is used in the management of generalized tonic-clonic, absence or mixed type seizures, but it does not come in an IV form. PO (per os) medications are inappropriate for this emergency situation. Magnesium sulfate is given to control seizures in toxemia of pregnancy.
17. C. Take the patient’s vital signs. Taking vital signs is within the education and scope of practice for a nursing assistant. The nurse should perform neurologic checks and document the seizure. Patients with seizures should not be restrained; however, the nurse may guide the patient’s movements as necessary. Focus: Delegation/supervision
18. B. 3-5% 
19. C. Myoclonic seizure . Myoclonic seizure is characterized by sudden uncontrollable jerking movements of a single or multiple muscle group.
20. B. The white blood cell count is 2300/mm3. Leukopenia is a serious adverse effect of phenytoin and would require discontinuation of the medication. The other data indicate a need for further assessment and/or patient teaching, but will not require a change in medical treatment for the seizures. Focus: Prioritization
21. D. The nurse should clear the area and position the client safely. The primary role of the nurse when a patient has a seizure is to protect the patient from harming him or herself.
22. D. A&C
23. B. Amitriptylene (Elavil), 10 mg QID. Elavil is an antidepressant that lowers the seizure threshold, so would not be appropriate for this patient. The other medications are anti-seizure drugs.
24. B. “The seizure may or may not mean your child has epilepsy.” There are many possible causes for a childhood seizure. These include fever, central nervous system conditions, trauma, metabolic alterations and idiopathic (unknown).
25. D. Maintain a patent airway. The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia.
26. B. Be drowsy and prone to sleep . Following a generalized seizure, the client frequently experiences drowsiness and postictal sleep. Answer A is incorrect because the client is able to move the extremities. Answer C is incorrect because the client can remember events before the seizure. Answer D is incorrect because the blood pressure is elevated.
27. C. Protects the client’s head from injury . Rhythmic contraction and relaxation associated with tonic-clonic seizure can cause repeated banging of head.
28. B. Set up oxygen and suction equipment. The LPN/LVN can set up the equipment for oxygen and suctioning. The RN should perform the complete initial assessment. Padded side rails are controversial in terms of whether they actually provide safety and ay embarrass the patient and family. Tongue blades should not be at the bedside and should never be inserted into the patient’s mouth after a seizure begins. Focus: Delegation/supervision.
29. D. Remove the child’s toys from the immediate area. Nursing care for a child having a seizure includes, maintaining airway patency, ensuring safety, administering medications, and providing emotional support. Since the seizure has already started, nothing should be forced into the child”s mouth and they should not be moved. Of the choices given, first priority would be for safety.
30. B. Restraining the client’s limbs. Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed.