Know What To Do When Someone Has A Convulsion Seizure - Safety Quiz

1. Seizures may be identified by

Jerking movements over entire body

Staring

Loss of awareness

Arm or leg jerking

All of the above

All of the listed symptoms - jerking movements over the entire body, staring, loss of awareness, and arm or leg jerking - can be indicators of seizures. Seizures can manifest in various ways, including convulsive movements, staring spells, and a temporary loss of consciousness. Therefore, all of the mentioned symptoms can help identify seizures.

Explanation

All of the listed symptoms - jerking movements over the entire body, staring, loss of awareness, and arm or leg jerking - can be indicators of seizures. Seizures can manifest in various ways, including convulsive movements, staring spells, and a temporary loss of consciousness. Therefore, all of the mentioned symptoms can help identify seizures.

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

Elevate the head of the bed.

Restrain the client’s arms and legs.

Place a tongue blade in the client’s mouth.

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.

Explanation

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.

3. 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?

The nurse should help the mother restrain the child to prevent him from injuring himself.

The nurse should call the operator to page for seizure assistance.

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.

Explanation

The primary role of the nurse when a patient has a seizure is to protect the patient from harming him or herself.

4. 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?

Place the child in the nearest bed

Administer IV medication to slow down the seizure

Place a padded tongue blade in the child's mouth

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.

Explanation

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.

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

Apply restraint so that the patient will not fall out of bed

Put a mouth gag so that the patient will not bite her tongue and the tongue will not fall back

.Position the mother on her side to allow the secretions to drain from her mouth and prevent aspiration

Check if the woman is also having a precipitate labor

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.

Explanation

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.

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

Hold the clients arms and leg firmly

Place the client immediately to soft surface

Protects the client’s head from injury

Attempt to insert a tongue depressor between the client’s teeth

Rhythmic contraction and relaxation associated with tonic-clonic seizure can cause repeated banging of head.

Explanation

Rhythmic contraction and relaxation associated with tonic-clonic seizure can cause repeated banging of head.

7. 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?

Place the patient on a non-rebreather mask will the oxygen at 15 L/minute.

Administer lorazepam (Ativan) 1 mg IV.

Turn the patient to the side and protect airway.

Assess level of consciousness during and immediately after the seizure.

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

Explanation

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

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

Pad the side rails

Place a pillow under the left buttock

Insert a padded tongue blade into the mouth

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.

Explanation

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.

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

Position the client on the side with head flexed forward

Elevate the head

Use tongue depressor between teeth

Loosen restrictive clothing

Positioning the client on one side with head flexed forward allows the tongue to fall forward and facilitates drainage secretions therefore prevents aspiration.

Explanation

Positioning the client on one side with head flexed forward allows the tongue to fall forward and facilitates drainage secretions therefore prevents aspiration.

10. Following a generalized seizure, the nurse can expect the client to:

Be unable to move the extremities

Be drowsy and prone to sleep

Remember events before the seizure

Have a drop in blood pressure

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.

Explanation

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.

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

Document the seizure.

Perform neurologic checks.

Take the patient’s vital signs.

Restrain the patient for protection.

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

Explanation

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

12. 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?

Loosening restrictive clothing

Restraining the client’s limbs

Removing the pillow and raising padded side rails

Positioning the client to side, if possible, with the head flexed forward

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.

Explanation

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.

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

Fever

Crackles in the lungs

Abdominal tenderness

Cardiac dysrhythmia

A fever in a 2-year-old child can assist in identifying the cause of a grand mal seizure because it suggests an infection or an inflammatory process as the underlying cause. Fevers can be triggered by various infections such as meningitis or encephalitis, which can lead to seizures. Therefore, the presence of a fever helps narrow down the potential causes of the seizure episode in this particular age group.

Explanation

A fever in a 2-year-old child can assist in identifying the cause of a grand mal seizure because it suggests an infection or an inflammatory process as the underlying cause. Fevers can be triggered by various infections such as meningitis or encephalitis, which can lead to seizures. Therefore, the presence of a fever helps narrow down the potential causes of the seizure episode in this particular age group.

14. 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?

"Do not worry. Epilepsy can be treated with medications."

"The seizure may or may not mean your child has epilepsy."

"Since this was the first convulsion, it may not happen again."

"Long term treatment will prevent future seizures."

"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).

Explanation

"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).

15. 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?

PO phenytoin and carbamazepine

IV lorazepam (Ativan)

IV carbamazepam

IV magnesium sulfate

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.

Explanation

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.

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

“You should avoid consumption of all forms of alcohol.”

“Wear you medical alert bracelet at all times.”

“Protect your loved one’s airway during a seizure.”

“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

Explanation

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

17. 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:

Short, abrupt muscle contraction

Quick, bilateral severe jerking movements

Abrupt loss of muscle tone

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.

Explanation

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.

18. 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?

In 30 to 45 seconds

In 10 to 15 minutes

In 30 to 45 minutes

In 1 to 2 hours

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.

Explanation

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.

19. 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?

Order a stat admission CBC.

Place a urine collection bag and specimen cup at the bedside.

Place a cooling mattress on his bed

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.

Explanation

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.

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

Maintain strict intake and output

Check the pulse before giving the medication

Administer the medication 30 minutes before meals

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.

Explanation

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.

21. 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?

Electrolyte imbalance

Head trauma

Epilepsy

Congenital defect

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.

Explanation

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.

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

Complete admission assessment.

Set up oxygen and suction equipment.

Place a padded tongue blade at bedside.

Pad the side rails before patient arrives.

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.

Explanation

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.

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?

Phenobarbitol, 150 mg hs

Amitriptylene (Elavil), 10 mg QID.

Valproic acid (Depakote), 150 mg BID

Phenytoin (Dilantin), 100 mg TID

Elavil is an antidepressant that lowers the seizure threshold, so would not be appropriate for this patient. The other medications are anti-seizure drugs.

Explanation

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. 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?

The medication can cause dental staining.

The client will need to avoid a high-carbohydrate diet.

The client will need a regularly scheduled CBC.

The medication can cause problems with drowsiness.

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.

Explanation

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.

25. 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?

The gums appear enlarged and inflamed.

The white blood cell count is 2300/mm3.

Patient occasionally forgets to take the phenytoin until after lunch.

Patient wants to renew his driver’s license in the next month.

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

Explanation

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

26. Seizures occur in approximately what percentage of children

1-3%

3-5%

5-8%

8-12%

Seizures occur in approximately 3-5% of children. This means that out of every 100 children, around 3 to 5 will experience seizures. Seizures are a common neurological disorder in children and can be caused by various factors such as epilepsy, fever, head injuries, or genetic conditions. It is important for parents and caregivers to be aware of the signs and symptoms of seizures in children and seek medical attention if necessary.

Explanation

Seizures occur in approximately 3-5% of children. This means that out of every 100 children, around 3 to 5 will experience seizures. Seizures are a common neurological disorder in children and can be caused by various factors such as epilepsy, fever, head injuries, or genetic conditions. It is important for parents and caregivers to be aware of the signs and symptoms of seizures in children and seek medical attention if necessary.

27. 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).

Document the onset time, nature of seizure activity, and postictal behaviors for all seizures.

Administer phenytoin (Dilantin) 200 mg PO daily.

Teach patient about the need for good oral hygiene.

Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.

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

Explanation

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

28. Seizures may be caused by but not limited to

Colds, strep throat, flu

Infection, injury, lack of sleep

Fever, trauma, infections, unknown

Allergies, ear infections, enuresis

All of the above

Seizures can be caused by various factors including fever, trauma, infections, and unknown reasons. Fevers can sometimes trigger seizures, especially in young children. Trauma to the brain, such as head injuries, can also lead to seizures. Infections, such as meningitis or encephalitis, can cause inflammation in the brain and result in seizures. Additionally, there are cases where seizures occur without any identifiable cause, hence referred to as unknown reasons. Therefore, all of the mentioned factors can contribute to the occurrence of seizures.

Explanation

Seizures can be caused by various factors including fever, trauma, infections, and unknown reasons. Fevers can sometimes trigger seizures, especially in young children. Trauma to the brain, such as head injuries, can also lead to seizures. Infections, such as meningitis or encephalitis, can cause inflammation in the brain and result in seizures. Additionally, there are cases where seizures occur without any identifiable cause, hence referred to as unknown reasons. Therefore, all of the mentioned factors can contribute to the occurrence of seizures.

29. 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?

Tonic seizure

Absence seizure

Myoclonic seizure

Clonic seizure

Myoclonic seizure is characterized by sudden uncontrollable jerking movements of a single or multiple muscle group.

Explanation

Myoclonic seizure is characterized by sudden uncontrollable jerking movements of a single or multiple muscle group.

30. Treatment plan for seizures includes

Clear area around child

Restrain jerking movements to prevent injury

Observe and document activitycall 911 if seizure activity lasts longer than 5 minutes

A&C

B&C

The correct answer is A&C because in the treatment plan for seizures, it is important to clear the area around the child to prevent any objects from causing harm during the seizure. Additionally, observing and documenting the activity is crucial for medical professionals to have a clear understanding of the seizure and its duration. Calling 911 if the seizure activity lasts longer than 5 minutes is also necessary as it may indicate a medical emergency that requires immediate attention.

Explanation

The correct answer is A&C because in the treatment plan for seizures, it is important to clear the area around the child to prevent any objects from causing harm during the seizure. Additionally, observing and documenting the activity is crucial for medical professionals to have a clear understanding of the seizure and its duration. Calling 911 if the seizure activity lasts longer than 5 minutes is also necessary as it may indicate a medical emergency that requires immediate attention.