MED SURG 2 EXAM 4 QUESTIONS
AND CORRECT ANSWERS 2024
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1. While the nurse is transporting a patient on a stretcher to the radiology department, the
patient begins having a tonic-clonic seizure.Which actionshould the nurse take
Insert an oral airway during the seizure to mainta...
,1. While the nurse is transporting a patient on a stretcher to the radiology department, the
patient begins having a tonic-clonic seizure. Which actionshould the nurse take
Insert an oral airway during the seizure to maintain a patent airway. Restrain the patient's
arms and legs to prevent injury during the seizure. Time and observe and record the details of
the seizure and postictal state. Avoid touching the patient to prevent further nervous system
stimulation.: -Time and observe and record the details of the seizure and postictal state.
Because the diagnosis and treatment of seizures frequently are based on the description of the seizure,
recording the length and details of the seizure is impor-tant. Insertion of an oral airway and restraining
the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease
the risk of injury during the seizure.
2. A high school teacher who has just been diagnosed with epilepsy after having a generalized
tonic-clonic seizure tells the nurse, "I cannot teach anymore, it will be too upsetting if I have a
seizure at work." Which responseby the nurse is best
"You might benefit from some psychologic counseling." "Epilepsy usually
can be well controlled with medications."
"You will want to contact the Epilepsy Foundation for assistance."
"The Department of Vocational Rehabilitation can help with work retraining."-
: "Epilepsy usually can be well controlled with medications."
3. A patient has been taking phenytoin (Dilantin) for 2 years. Which action willthe nurse take
,when evaluating for adverse effects of the medication
Inspect the oral mucosa. Listen to
the lung sounds. Auscultate the
bowel tones.
Check pupil reaction to light.: Inspect the oral mucosa.
Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lungsounds, or pupil
reaction to light.
4. A patient reports feeling numbness and tingling of the left arm before experiencing a tonic-
clonic seizure. The nurse determines that this history isconsistent with what type of seizure
, Focal
Atonic
Absence
Myoclonic: Focal
The initial symptoms of a focal seizure involve clinical manifestations that are localized to a particular
part of the body or brain. Symptoms of an absence seizureare staring and a brief loss of consciousness.
In an atonic seizure, the patient losesmuscle tone and (typically) falls to the ground. Myoclonic seizures
are characterizedby a sudden jerk of the body or extremities.
5. A 73-year-old patient with Parkinson's disease has a nursing diagnosis of impaired physical
mobility related to bradykinesia. Which action will the nurseinclude in the plan of care
Instruct the patient in activities that can be done while lying or sitting. Suggest that the patient
rock from side to side to initiate leg movement. Have the patient take small steps in a straight line
directly in front of the feet.Teach the patient to keep the feet in contact with the floor and slide
them forward.: Suggest that the patient rock from side to side to initiate leg movement.
Rocking the body from side to side stimulates balance and improves mobility. The patient will be
encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide
base of support will help with balance. Thepatient should lift the feet and avoid a shuffling gait.
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