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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Restlessness and altered mental status are early signs of increasing intracranial pressure, resulting from cerebral edema compressing neural tissue and reducing oxygen supply to critical brain regions.
Choice B rationale
Widening pulse pressure is a later sign of increased intracranial pressure, indicating significant disruption of autonomic regulation and brainstem function. Early symptoms like restlessness occur first.
Choice C rationale
Fixed and dilated pupils signify severe and advanced intracranial pressure, often indicating brain herniation, which is a critical stage beyond initial compensatory mechanisms.
Choice D rationale
Tachycardia and hypotension are not hallmark signs of raised intracranial pressure. Bradycardia and hypertension align more closely with Cushing's triad, associated with late-stage intracranial hypertension. .
Correct Answer is C
Explanation
Choice A rationale
Subarachnoid hemorrhage is less likely given the sudden decrease in consciousness. This type of injury typically results in severe headache or focal neurological deficits, not rapid mental decline.
Choice B rationale
Diffuse axonal injury usually presents with persistent unconsciousness rather than sudden deterioration. It results from widespread shearing forces and is less likely with the reported history.
Choice C rationale
Epidural hematoma often presents with a lucid interval followed by sudden neurological decline, as described in this case. Rapid accumulation of blood between the dura and skull can compress brain tissue.
Choice D rationale
Subdural hematoma tends to cause gradual neurological deterioration rather than a sudden decrease in Glasgow Coma Scale. This occurs due to slower venous bleeding. .
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