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 C
Explanation
Choice A rationale
Childhood memory recall reflects cognitive functioning but is unrelated to the patient's rehabilitation involvement, which focuses on regaining lost functional capacities following injury. Such a goal lacks immediate functional relevance.
Choice B rationale
Returning to work as a corporate attorney may be an eventual aim but depends on higher cognitive recovery levels and is too specific. Early rehabilitation outcomes focus on participation in the recovery process.
Choice C rationale
Active participation indicates readiness and willingness to engage in therapies essential for regaining lost functions. It aligns with goals for a transition from acute care to rehabilitation emphasizing functional improvement.
Choice D rationale
Motor coordination improvements require therapy timelines extending beyond two weeks. Such a rigid short-term goal undermines individualized rehabilitation focusing on measurable progress over more realistic durations.
Correct Answer is A
Explanation
Choice A rationale
Cerebellar injury affects balance and coordination; ensuring bed alarm use prioritizes safety for patients who are at high fall risk due to impaired motor control and unsteady gait.
Choice B rationale
Reorientation addresses confusion, often linked to cognitive or frontal brain injuries, not cerebellar function, which mainly regulates coordination and balance rather than higher-order thinking.
Choice C rationale
Turning every 2 hours prevents skin breakdown but is more relevant to immobilized patients, not those with cerebellar injuries where mobility and fall prevention are the primary concerns.
Choice D rationale
Varying the schedule may stimulate engagement but does not directly address fall risks or coordination issues, which are critical for patients with cerebellar injuries.
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