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: To administer medications and electrolytes is not the best reply for why the client will need the NG tube, because this is not the primary purpose of the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration. Medications and electrolytes can be given through the IV route.
Choice B Reason: To dilate the stomach as a presurgical preparation is not the best reply for why the client will need the NG tube, because this is not a valid indication for the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration. Dilation of the stomach is not a goal of presurgical preparation, but rather an adverse effect of gastric obstruction.
Choice C Reason: You will not be able to eat for several days is not the best reply for why the client will need the NG tube, because this is not a complete or accurate explanation of the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration. The client will not be able to eat for several days because of the NPO diet, which is necessary to rest the inflamed peritoneum and reduce the risk of complications.
Choice D Reason: To remove secretions and decompress your stomach is the best reply for why the client will need the NG tube, because this is a clear and correct explanation of the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration, which are common symptoms of acute peritonitis. By removing secretions and decompressing the stomach, the NG tube can reduce pain, inflammation, and infection in the abdominal cavity.
Correct Answer is C
Explanation
Choice A Reason: Reporting itching if it becomes bothersome is part of client teaching, as it may indicate inflammation or infection of the ear canal. External otitis is also known as swimmer's ear, as it can be caused by water trapped in the ear after swimming or bathing.
Choice B Reason: Using earplugs when swimming is part of client teaching, as it can prevent water from entering and irritating the ear canal. External otitis can be prevented by keeping the ear dry and avoiding trauma or foreign objects.
Choice C Reason: This is the correct choice. Inserting a cotton-tip applicator to remove excess wax is not part of client teaching, as it can damage or scratch the ear canal and increase the risk of infection. Wax helps protect and lubricate the ear canal and should not be removed unless it causes hearing impairment or discomfort.
Choice D Reason: Using a hairdryer set to low, 6 inches away from ear is part of client teaching, as it can help dry the ear canal after swimming or bathing. External otitis can be treated by applying warm compresses, using topical antibiotics or antifungals, and taking pain relievers or anti-inflammatory drugs.
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