Seizures & Epilepsy
This is the most appropriate nursing action when a patient is experiencing a generalized tonic-clonic seizure.
What is turning the patient on their side and protecting their head?
Rationale: Turning the patient on their side prevents aspiration, and protecting their head minimizes the risk of head trauma. Restraining or inserting objects into the mouth can cause more harm.
A transient ischemic attack (TIA) is considered a warning sign for this major neurological event.
What is a stroke?
Rationale: A TIA is a temporary blockage of blood flow to the brain and serves as a warning that a stroke may occur in the future.
A patient with hyperthyroidism may present with this prominent eye-related symptom.
What is exophthalmos?
Rationale: Exophthalmos (bulging eyes) is commonly seen in Graves’ disease, a form of hyperthyroidism.
The nurse should advise diabetic patients to monitor for this effect when taking levothyroxine.
What is hyperglycemia?
Rationale: Levothyroxine can increase blood sugar levels, so diabetic patients should monitor their glucose closely.
This classic symptom of meningitis involves neck stiffness.
What is nuchal rigidity?
Rationale: Nuchal rigidity (stiff neck) is a classic sign of meningitis.
A patient taking phenytoin (Dilantin) should be monitored for this oral health complication.
What is gingival hyperplasia?
Rationale: Phenytoin (Dilantin) is known to cause gingival hyperplasia, an overgrowth of gum tissue. Good oral hygiene and regular dental visits are recommended.
A stroke affecting the right hemisphere may lead to this behavioral characteristic.
What is impulsivity and safety risks?
Rationale: Right hemisphere strokes often lead to impulsivity, poor judgment, and neglect of the left side of the body.
In a thyrotoxic crisis (thyroid storm), the nurse expects to see all of the following symptoms except this one.
a) Hyperthermia
b) Tachycardia
c) Bradycardia
d) Agitation
What is bradycardia?
Rationale: Thyroid storm leads to increased heart rate and temperature, not bradycardia.
When should Lispro (Humalog) insulin be administered?
Immediately before or within 15 minutes of eating
Rationale: Lispro is a rapid-acting insulin that works quickly and must be taken right before eating.
The first priority when admitting a patient with suspected bacterial meningitis.
a) Administering acetaminophen
b) Obtaining blood cultures
c) Providing oxygen
d) Performing a lumbar puncture
What is obtaining blood cultures before starting antibiotics?
Rationale: Blood cultures must be obtained before starting antibiotics to ensure proper treatment.
A nurse educating a seizure patient should emphasize this most important aspect of medication adherence.
What is taking medication at the same time every day?
Rationale: Anti-seizure medications need to be taken consistently to maintain therapeutic levels and prevent breakthrough seizures.
A patient experiencing difficulty swallowing after a stroke should undergo this assessment before oral feeding.
What is a swallow assessment?
Rationale: A swallow assessment is critical to prevent aspiration in stroke patients.
This emergency condition in hypothyroidism can lead to respiratory failure and coma.
What is myxedema coma?
Rationale: Myxedema coma is a severe hypothyroid state that can cause respiratory failure, bradycardia, and hypothermia.
A diabetic patient should check their blood glucose at 2–3 AM to monitor for which condition(s)?
What is the dawn phenomenon & Somogyi effect?
Rationale: The dawn phenomenon is a natural increase in blood sugar in the early morning due to hormonal shifts.
The Somogyi effect is rebound hyperglycemia after nighttime hypoglycemia
A patient with suspected West Nile Virus encephalitis is at risk for this major neurological complication.
What is seizures and altered level of consciousness?
Rationale: Encephalitis can cause seizures and decreased consciousness due to brain inflammation.
When a seizure patient has no known trigger, this is the term used to describe the cause
What is idiopathic?
Rationale: Idiopathic seizures have no identifiable cause, whereas febrile seizures occur due to fever, and psychogenic seizures are non-epileptic events.
This diagnostic test is first ordered to determine whether a stroke is ischemic or hemorrhagic.
What is a CT scan without contrast?
Rationale: A CT scan without contrast is used first to determine if a stroke is ischemic or hemorrhagic.
This treatment for Graves' disease destroys thyroid tissue to reduce hormone production.
What is radioactive iodine therapy?
Rationale: Radioactive iodine therapy selectively destroys overactive thyroid tissue to reduce hormone production.
A patient with Type 2 Diabetes experiencing unexplained weight loss and fatigue may be experiencing this serious condition.
a) Hyperthyroidism
b) Diabetic ketoacidosis (DKA)
c) Addison’s disease
d) Cushing’s syndrome
What is diabetic ketoacidosis (DKA)?
Rationale: DKA is characterized by rapid weight loss, dehydration, and extreme fatigue due to insulin deficiency.
A 19-year-old with suspected bacterial meningitis will likely exhibit these symptoms.
a) Low-grade fever
b) Cough and sore throat
c) High fever, photophobia, and headache
d) Abdominal pain
What is high fever, photophobia, headache, and nuchal rigidity?
Rationale: Bacterial meningitis presents with fever, stiff neck, light sensitivity, and headache.
What should a nurse do immediately after a patient has a generalized tonic-clonic seizure?
What is allow the patient to rest in a safe environment?
Rationale: Postictal confusion and fatigue are normal after a seizure. The priority is ensuring a safe environment while the patient recovers.
A 70-year-old patient with left-sided weakness, slurred speech, and facial drooping arrives at the ER. What should the nurse expect next for ruling in or ruling out a hemorrhagic stroke vs. ischemic stroke?
Obtain a CT scan of the head
Rationale: A CT scan is required immediately to determine if the stroke is ischemic or hemorrhagic before treatment decisions (e.g., tPA) can be made.
A patient with hyperparathyroidism is at high risk for which complication?
Renal Calculi
Rationale: Hyperparathyroidism leads to increased calcium levels, which can cause kidney stones, osteoporosis, and muscle weakness.
A patient with Type 2 diabetes on metformin reports muscle pain and fatigue. What should the nurse do?
What is check renal function tests and report immediately?
Rationale: Metformin can cause lactic acidosis, a serious condition that presents with muscle pain and fatigue. Kidney function must be assessed immediately.
Which of the following findings is most concerning in a patient with increased intracranial pressure (ICP)?
What is Increased drowsiness and confusion?
Rationale: Drowsiness and confusion suggest worsening brain swelling and herniation risk, requiring immediate intervention.