A nurse reviewing a client's chart reads that the client was observed having a complex partial seizure with automatisms of the face. What does the nurse understand this to mean?
During a seizure, the client lost bladder control
During a seizure, the client's eyes remained fixed and dilated
During a seizure, the client made involuntary groaning sounds
During a seizure, the client had involuntary facial movements, such as lip-smacking
The Correct Answer is D
Choice A Reason: This choice is incorrect. Losing bladder control is not a feature of complex partial seizures, but rather of generalized tonic-clonic seizures. Complex partial seizures are a type of focal seizures that affect a specific area of the brain and cause impaired awareness and automatisms. Automatisms are repetitive and involuntary movements or behaviors that occur during a seizure.
Choice B Reason: This choice is incorrect. Having fixed and dilated eyes is not a feature of complex partial seizures, but rather of brain death or severe brain injury. Complex partial seizures do not affect the pupils or eye movements, but rather the level of consciousness and motor activity.
Choice C Reason: This choice is incorrect. Making involuntary groaning sounds is not a feature of complex partial seizures, but rather of simple partial seizures. Simple partial seizures are a type of focal seizures that affect a specific area of the brain and do not impair awareness or cause automatisms. They can cause sensory, motor, or psychic symptoms, such as auditory or visual hallucinations, tingling sensations, or emotional changes.
Choice D Reason: This is the correct choice. Having involuntary facial movements, such as lip-smacking, is a feature of complex partial seizures. Complex partial seizures often originate from the temporal lobe of the brain, which is involved in memory, language, and emotion. They can cause automatisms that affect the mouth, face, or hands, such as chewing, swallowing, picking, or fidgeting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because nystagmus is not a response to stimuli, but a condition that causes involuntary eye movements. Nystagmus can be caused by various factors, such as inner ear disorders, brain lesions, or drug toxicity, but not necessarily by cervical spine injury.
Choice B Reason: This is incorrect because decorticate positioning is a response to stimuli that indicates damage to the cerebral cortex or the corticospinal tract. Decorticate positioning is characterized by flexion of the arms and extension of the legs. It does not indicate cervical spine injury, which affects the spinal cord below the brainstem.
Choice C Reason: This is incorrect because lack of any response to stimuli can indicate various levels of brain damage or coma, but not specifically cervical spine injury. Lack of any response can also be influenced by other factors, such as sedation, hypothermia, or shock.
Choice D Reason: This is correct because decerebrate positioning is a response to stimuli that indicates damage to the brainstem or the upper cervical spine. Decerebrate positioning is characterized by extension and outward rotation of the arms and legs. It indicates a severe and life-threatening injury that can impair vital functions, such as breathing and blood pressure.
Correct Answer is C
Explanation
Choice A Reason: This is correct because incorporating foods rich in vitamin C in the diet can help prevent or delay macular degeneration. Vitamin C is an antioxidant that can protect the cells of the macula, which is the central part of the retina that is responsible for sharp and detailed vision, from oxidative stress and damage. The nurse should also advise the client to consume foods rich in other antioxidants, such as vitamin E, zinc, lutein, and zeaxanthin.
Choice B Reason: This is correct because receiving injections into the eye can help treat macular degeneration. Injections are a form of anti-vascular endothelial growth factor (anti-VEGF) therapy, which can block abnormal blood vessel growth and leakage in the macula that can cause vision loss. The nurse should explain to the client how often and how long they need to receive injections and what side effects or complications they may experience.
Choice C Reason: This is incorrect because vision will not be restored after using eye drops for macular degeneration. Eye drops are not a proven or effective treatment for macular degeneration, which is a chronic and progressive condition that causes irreversible vision loss. The nurse should reinforce education by informing the client that eye drops may only provide temporary relief of dryness or irritation, but they will not improve or restore vision.
Choice D Reason: This is correct because vision will become progressively more blurry with macular degeneration. Macular degeneration can cause blurred or distorted central vision, difficulty reading or recognizing faces, or dark spots in the visual field. The nurse should educate the client on how to cope with vision loss and use adaptive devices, such as magnifiers, large-print books, or voice-activated technology.
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