A nurse assesses clients on a medical-surgical unit. Which ...

[savannahhooper]

A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for secondary seizures? (Select all that apply.)
 
  a. A 26-year-old woman with a left temporal brain tumor
  b. A 38-year-old male client in an alcohol withdrawal program
  c. A 42-year-old football player with a traumatic brain injury
  d. A 66-year-old female client with multiple sclerosis
  e. A 72-year-old man with chronic obstructive pulmonary disease

Question 2

A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.)
 
  a. Intermittent rigidity
  b. Lip smacking
  c. Sudden loss of muscle tone
  d. Brief jerking of the extremities
  e. Picking at clothing
  f.
  Patting of the hand on the leg

[yuyiding]

Answer to Question 1

ANS: A, B, C
Clients at risk for secondary seizures include those with a brain lesion from a tumor or trauma, and those who are experiencing a metabolic disorder, acute alcohol withdrawal, electrolyte disturbances, and high fever. Clients with a history of stroke, heart disease, and substance abuse are also at risk. Clients with multiple sclerosis or chronic obstructive pulmonary disease are not at risk for secondary seizures.

Answer to Question 2

ANS: B, E, F
Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, picking at clothing, and patting. Rigidity of muscles is associated with the tonic phase of a seizure, and jerking of the extremities is associated with the clonic phase of a seizure. Loss of muscle tone occurs with atonic seizures.