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 B
Explanation
Choice A Reason: An antifungal cream is not indicated for a sty, which is an infection of the eyelash follicle or sebaceous gland caused by bacteria.
Choice B Reason: This is the correct answer because warm compresses can help relieve pain and inflammation, and promote drainage of the sty.
Choice C Reason: Ice and cold compresses are not recommended for a sty, as they can constrict blood vessels and delay healing.
Choice D Reason: There is no need to test the other eye for vision loss, as a sty does not affect vision unless it is very large or obstructs the pupil.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because airway obstruction is the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Airway obstruction can occur due to edema, inflammation, or inhalation injury of
the upper airway structures. It can compromise oxygenation and ventilation, and lead to respiratory failure or cardiac arrest. The nurse should assess for signs of airway obstruction, such as stridor, hoarseness, dyspnea, or cyanosis, and provide oxygen therapy, humidification, or intubation as needed.
Choice B reason: This is incorrect because fluid imbalance is not the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Fluid imbalance can occur due to fluid loss from damaged skin and capillaries, as well as increased capillary permeability and fluid shifts. It can cause dehydration, hypovolemia, shock, or electrolyte imbalances. The nurse should monitor fluid status, vital signs, urine output, and laboratory values, and provide fluid resuscitation as prescribed, but only after ensuring airway patency.
Choice C reason: This is incorrect because paralytic ileus is not the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Paralytic ileus is a condition where there is decreased or absent bowel motility due to nerve damage or decreased blood flow to
the gastrointestinal tract. It can cause abdominal distension, nausea, vomiting, or constipation. The nurse should assess bowel sounds, abdominal girth, and stool characteristics, and provide nasogastric suction or laxatives as prescribed, but only after ensuring airway patency and fluid balance.
Choice D reason: This is incorrect because infection is not the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Infection can occur due to loss of skin barrier, exposure to microorganisms, or impaired immune system. It can cause fever, increased pain, purulent drainage, or sepsis. The nurse should assess for signs of infection, obtain wound cultures, and administer antibiotics as prescribed, but only after ensuring airway patency, fluid balance, and pain control.
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