A patient had a tonic-clonic seizure. Which findings does the ...

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A patient had a tonic-clonic seizure. Which findings does the nurse evaluate as indicating the patient is in a postictal state? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.
 
  1. The patient is incontinent of urine.
  2. The patient is in a deep sleep.
  3. The patient is confused as to place and time.
  4. The patient reports an odd taste in his mouth.
  5. The patient is attempting to remove his hospital gown.

Question 2

The patient receives reteplase (Retavase) intravenously (IV). The nurse assesses the patient for orientation and level of consciousness. The patient's wife asks the nurse why this is being done. What does the nurse indicate as the reason for the assessment?
 
  1. The medication can alter fluid balance; this affects orientation and level of consciousness.
  2. The medication can cause bleeding in the brain; this affects orientation and level of consciousness.
  3. The medication causes hypoglycemia; this affects orientation and level of consciousness.
  4. The medication decreases oxygen to the brain; this decreases orientation and level of consciousness.

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Answer to Question 1

2,3
Rationale 1: Incontinence of bowel or bladder is common during a tonic-clonic seizure but is not indicative of a postictal state.
Rationale 2: Deep sleep after the seizure is a finding associated with the postictal state.
Rationale 3: Patients who are in the postictal state may be confused and disoriented.
Rationale 4: An odd taste, specific odor or noise, or other sensory change often heralds a seizure. This is called an aura.
Rationale 5: During complex partial seizures, patients sometimes fumble with or attempt to remove clothing.

Global Rationale: Deep sleep after the seizure is a finding associated with the postictal state. Patients who are in the postictal state may be confused and disoriented. Incontinence of bowel or bladder is common during a tonic-clonic seizure but is not indicative of a postictal state. An odd taste, specific odor or noise, or other sensory change often heralds a seizure. This is called an aura. During complex partial seizures, patients sometimes fumble with or attempt to remove clothing.

Answer to Question 2

2
Rationale 1: Reteplase (Retavase) does not alter fluid balance in the body.
Rationale 2: Cerebral hemorrhage is a concern with reteplase (Retavase) therapy; the nurse must assess for changes in mental and neurological status.
Rationale 3: Reteplase (Retavase) does not cause hypoglycemia.
Rationale 4: Reteplase (Retavase) does not decrease oxygen to the brain.
Global Rationale: Cerebral hemorrhage is a concern with reteplase (Retavase) therapy; the nurse must assess for changes in mental and neurological status. Reteplase (Retavase) does not decrease oxygen to the brain. Reteplase (Retavase) does not cause hypoglycemia. Reteplase (Retavase) does not alter fluid balance in the body.

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Gracias!

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Excellent