The nurse observes increased eye blinking and lip smacking in a client who has a history of absence seizures.
The nurse is aware these symptoms indicate:

Automatisms associated with this type of seizure.

The client may have been exposed to a neurotoxin.

An electrolyte imbalance, likely hyponatremia.

A reversible adverse effect of anticonvulsant drugs.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Automatisms, such as eye blinking and lip smacking, are repetitive, involuntary movements commonly associated with absence seizures. They occur due to brief interruptions in consciousness during seizure activity without major motor involvement.

Choice B rationale

Neurotoxin exposure typically presents with symptoms like weakness, ataxia, and autonomic dysfunction. Increased eye blinking and lip smacking are not specific to neurotoxin-related neurological damage or poisoning.

Choice C rationale

Hyponatremia causes confusion, lethargy, and muscle cramps due to electrolyte disturbance affecting cellular function, but it does not cause specific automatisms like eye blinking or lip smacking in seizure-related conditions.

Choice D rationale

Reversible adverse effects of anticonvulsants often include sedation or cognitive slowing. Automatisms such as blinking and smacking are not typically linked to the pharmacological effects of anticonvulsants.

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Correct Answer is C

Explanation

Choice A rationale

While bleeding could indicate trauma, EEG does not detect blood presence or volume but instead evaluates electrical brain activity indicative of neuronal function.

Choice B rationale

Cerebral oxygen intake assessment requires pulse oximetry or arterial blood gas analysis rather than EEG, which monitors electrical signals, not oxygenation status.

Choice C rationale

EEG identifies abnormal brain wave patterns suggesting ongoing seizure activity, even in sedated patients, aiding in targeted interventions and preventing potential complications.

A. Prevent the drainage by applying a pressure dressing. B. Allow fluid to drain from the patient's ear onto gauze and notify the provider. C. Hang intravenous (IV) fluids to replace fluids lost. D. Administer antibiotics due to increased risk of infection.

Correct Answer is B

Explanation

Choice A rationale

Applying pressure to prevent drainage could force cerebrospinal fluid (CSF) back into the cranial cavity, increasing infection risk and intracranial pressure, potentially worsening brain injury. CSF leakage requires non-obstructive handling.

Choice B rationale

Allowing fluid to drain onto gauze prevents build-up of intracranial pressure while assessing for halo sign, indicating CSF leakage. Yellow staining reflects glucose presence in CSF, confirming dura mater damage.

Choice C rationale

Intravenous fluids manage hypovolemia but are not prioritized for trauma patient brain injuries. Replacing lost CSF requires specific medical intervention rather than fluid volume adjustments alone.

Choice D rationale

Antibiotics treat infections but are not first priority for confirmed CSF leakage, which demands careful monitoring of drainage to prevent neurological damage. Post-intervention antibiotics may be necessary.

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The nurse observes increased eye blinking and lip smacking in a client who has a history of absence seizures.The nurse is aware these symptoms indicate:

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Correct Answer is C

Explanation

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Correct Answer is B

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The nurse observes increased eye blinking and lip smacking in a client who has a history of absence seizures.
The nurse is aware these symptoms indicate: