A patient diagnosed with a seizure disorder tells the nurse that they feel like they have "butterflies" in their stomach. The patient has felt this in the past before having a seizure. The nurse recognizes that this feeling is:
an anxiety disorder.
related to hunger.
an aura.
a postictal sign.
The Correct Answer is C
A. While anxiety can cause gastrointestinal symptoms, the context of this patient’s experience with seizures indicates that it is specifically related to the seizure disorder rather than an independent anxiety issue.
B. The sensation of "butterflies" is not typically related to hunger, as hunger is more commonly associated with physical feelings of emptiness or pain rather than a specific butterfly sensation.
C. An aura is a perceptual disturbance experienced by some patients with seizure disorders that precedes a seizure. It can manifest as various sensations, including gastrointestinal feelings like "butterflies," which serve as a warning sign that a seizure is imminent.
D. A postictal sign refers to the state of confusion or altered consciousness following a seizure, rather than sensations experienced prior to the seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While using a cane or walker may be necessary for some patients experiencing balance issues, it is not a specific instruction related to phenytoin.
B. Phenytoin dosages should not be adjusted solely based on observed seizure activity; the dose must be managed carefully based on serum drug levels and the clinician's guidance.
C. Patients on phenytoin typically require more frequent monitoring of blood levels (every 2-3 months initially) rather than annually, as maintaining therapeutic levels is essential to avoid toxicity or ineffective seizure control.
D. Regular dental visits are crucial for patients taking phenytoin because the medication can cause gingival hyperplasia (overgrowth of gum tissue), which necessitates careful dental hygiene and regular monitoring by a dentist to prevent complications.
Correct Answer is B
Explanation
A. 1:1 observation may be excessive unless the behavior is persistent and unmanageable.
B. Pointing out the behavior as unacceptable provides immediate feedback and helps the patient understand social boundaries, which can be challenging post-brain injury. This approach is direct and respectful, focusing on redirection rather than punishment.
C. Asking why may not be effective, as the patient may lack insight into their behavior due to the brain injury.
D. Having the patient return to their room could seem punitive and does not address the need for behavior modification.
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