A patient is admitted to the Emergency Department (ED). The nurse documents "postictal upon transfer" as evidenced by which observation?

Abnormal sensory sensations including tingling of the skin

Yellowing of the skin

Severe itching of the eyes

Is in a drowsy confused state after a seizure

Answer and Explanation

The Correct Answer is D

A. Abnormal sensory sensations such as tingling may be associated with the aura phase of a seizure but are not typically observed postictally.

B. Yellowing of the skin is usually indicative of jaundice, unrelated to seizure activity or the postictal state.

C. Itching of the eyes is unrelated to seizure activity and would not typically be documented in the context of postictal observations.

D. The postictal state is characterized by drowsiness, confusion, and other altered mental statuses that follow a seizure. This period can vary in duration depending on the patient and seizure type.

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Correct Answer is C

Explanation

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.

A. after the client has an electroencephalogram (EEG)." B. due to having minimal risk for infection." C. by threading it through the femoral artery to the brain." D. to monitor intracranial pressure (ICP) and drain the cerebral spinal fluid."

Correct Answer is D

Explanation

A. EEG is a monitoring tool for brain activity, but it is not a prerequisite for ventriculostomy placement.

B. While the procedure is carefully managed to reduce infection risk, ventriculostomy does have an infection risk due to its invasive nature.

C. Ventriculostomy is not inserted via the femoral artery; it is placed directly in the brain’s ventricles.

D. A ventriculostomy is used to monitor ICP and allows for the drainage of cerebrospinal fluid, which helps in managing elevated ICP in patients with brain injuries.

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A patient is admitted to the Emergency Department (ED). The nurse documents "postictal upon transfer" as evidenced by which observation?

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Naxlex Comprehensive Predictor Exams

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:

Correct Answer is C

Explanation

The nurse is educating on the placement of a ventriculostomy (intraventricular catheter) to the patient diagnosed with a brain injury and their family. The nurse states, "The ventriculostomy is placed:

Correct Answer is D

Explanation

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