Neurological issues

Question 1

1. A male patient with a metastatic brain tumor has a generalized seizure. He is vomiting. The family calls for the nurse. What should the nurse do first?
   A) Obtain supplies to suction.
   B) Page or call the physician.
   C) Insert a wooden tongue blade into his mouth.
   D) Turn him on his side.

Answer 1

Ans:  D
Chapter:  65
Client Needs:  D-3
Cognitive Level:  Application
Difficulty:  Moderate
Integrated Process:  Nursing Process
Objective:  3
Page and Header:  1981, Primary Brain Tumors

Feedback: The nurse’s first response should be to place the patient on his side to prevent him from aspirating emesis. Inserting something into the seizing patient’s mouth is no longer part of a seizure protocol. Obtaining supplies to suction the patient would be a delegated task. Paging or calling the physician would only be necessary if this is the patient’s first seizure.

Question 2

The nurse develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child’s bedside?

1. Emergency cart
2. Tracheotomy set
3. Padded tongue blade
4. Suctioning equipment and oxygen

Answer 2

Suctioning equipment and oxygen

Question 3

The nurse develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child’s bedside?

1. Emergency cart
2. Tracheotomy set
3. Padded tongue blade
4. Suctioning equipment and an airway

Answer 3

Answer 4

Generalized seizures caused rigidity of all body muscles, followed by intense jerking movements. Because airway obstruction and increased secretions can occur during the seizure, airway and suctioning equipment are placed at bedside. A tracheotomy is not performed during a seizure. An emergency card would not be left at beside but would be available in the treatment room or the nearby nursing unit.