Author Question: A child has had an episode of lip smacking while staring into space, but did not seem to lose ... (Read 81 times)

rlane42 · **on:** Jun 28, 2018

A child has had an episode of lip smacking while staring into space, but did not seem to lose consciousness. She was confused afterward but said her hands felt tingly before the other symptoms started. How should the nurse document this event?

A.
Alteration in consciousness
B.
Convulsion
C.
Focal seizure
D.
Generalized seizure

Question 2

A child has an invasive intracranial pressure monitoring device in place. Which assessment finding indicates that goals for a priority nursing diagnosis have been met?

A.
Daily weight equals admission weight.
B.
Joints move freely during range of motion.
C.
No signs of infection are present at the insertion site.
D.
Skin is intact without redness or breakdown.

mochi09 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: C
A focal seizure involves only one part of the brain and manifests with involuntary movements, sensory symptoms, possible staring into space, no loss of consciousness, and confusion afterward. Alteration in consciousness is too vague in this case to be a useful description. Convulsion is an outdated term. A generalized seizure involves both hemispheres of the brain and manifestations usually include loss of consciousness and tonic-clonic movements.

Answer to Question 2

ANS: C
All indications show that goals for various nursing diagnoses have been met; however, the priority here would be preventing infection at the intracranial pressure monitoring site, which would have a direct route to the brain.