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: A facial tumor is not related to Guillain-Barre syndrome, which is an autoimmune disorder that affects the peripheral nerves.
Choice B Reason: Pregnancy is not a risk factor for Guillain-Barre syndrome, although it can occur during or after pregnancy in rare cases.
Choice C Reason: A puncture wound 3 weeks ago is unlikely to cause Guillain-Barre syndrome, which usually follows a respiratory or gastrointestinal infection.
Choice D Reason: This is the correct answer because cytomegalovirus is one of the common infections that can trigger Guillain-Barre syndrome. It can cause inflammation and damage to the myelin sheath that covers the nerves.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because a referral to a sleep study program is not the most appropriate plan of care for a blind client who has difficulty with sleep. A sleep study program is used to diagnose and treat sleep disorders such as sleep apnea, narcolepsy, or restless legs syndrome.
Choice B Reason: This is incorrect because assisting the client to see if a night shift job is available is not a helpful plan of care for a blind client who has difficulty with sleep. A night shift job can disrupt the circadian rhythm and worsen the sleep quality and quantity of the client.
Choice C Reason: This is incorrect because institution of opioids and sedatives is not a safe plan of care for a blind client who has difficulty with sleep. Opioids and sedatives can cause addiction, dependence, tolerance, and withdrawal symptoms. They can also impair the respiratory and cognitive functions of the client.
Choice D Reason: This is the correct choice because education about non-24 disorder is an essential plan of care for a blind client who has difficulty with sleep. Non-24 disorder is a condition where the internal clock of the body does not synchronize with the 24-hour day-night cycle. It can cause irregular sleep patterns, daytime fatigue, and mood disturbances. It is more common in blind people who lack light perception. The nurse should educate the client about the causes, symptoms, and treatments of non-24 disorder.
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