The nurse knows that the client with a history of epilepsy might also have what nursing diagnosis?
1. Impaired gas exchange
2. Risk for injury
3. Chronic pain
4. Risk for infection
Correct Answer: 2
Rationale 1: Impaired gas exchange is incorrect because chronic pain, risk for infection, and impaired gas exchange do not apply to epilepsy.
Rationale 2: A seizure is a disturbance of electrical activity in the brain that can affect consciousness, motor activity, and sensation. Some seizures involve convulsions, which are involuntary, violent spasms of the large skeletal muscles of the face, neck, arms, and legs. Because convulsions are involuntary, serious injury can occur.
Rationale 3: Chronic pain is incorrect because chronic pain, risk for infection, and impaired gas exchange do not apply to epilepsy.
Rationale 4: Risk for infection is incorrect because chronic pain, risk for infection, and impaired gas exchange do not apply to epilepsy.
Global Rationale: A seizure is a disturbance of electrical activity in the brain that can affect consciousness, motor activity, and sensation. Some seizures involve convulsions, which are involuntary, violent spasms of the large skeletal muscles of the face, neck, arms, and legs. Because convulsions are involuntary, serious injury can occur. Impaired gas exchange is incorrect because chronic pain, risk for infection, and impaired gas exchange do not apply to epilepsy. Chronic pain is incorrect because chronic pain, risk for infection, and impaired gas exchange do not apply to epilepsy. Risk for infection is incorrect because chronic pain, risk for infection, and impaired gas exchange do not apply to epilepsy.
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