Hesi Case Study Seizure Disorder 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.
- Prioritize the nursing actions: - 1st Safely move the client to the
- What action should the nurse implement next? - Note the time,
- Which intervention should the nurse implement? - Turn him to the
- To help determine why the seizure activity started, which question should
floor.2nd Push the furniture away from the client.3rd Remove people from the waiting room.4th Assess the client's blood pressure.After initial interventions are implemented, the man continues to have a tonic- clonic seizure.
duration, and type of seizure 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.
side and allow the client to sleep 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.
the nurse ask Alanna? - "Have you ever had any type of head injury?"Do you have a history of drinking alcohol?" 1 / 2
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?"
- Which response by the nurse is correct? - "It is a visual or auditory
- Which action should the nurse include in preparing Alanna for the EEG?
- Instruct the client to refrain from consuming caffeine prior to the EEG
- Which statement by the nurse is the best response?A) "The test will rule out
- Which statement indicates that Alanna understands the client teaching?
- "I must brush and floss my teeth after every meal."
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warning that the seizure is about to start." 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.
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."
many possible causes of seizures." - "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.
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.