A patient had a tonic-clonic seizure. Which findings does the nurse evaluate as indicating the patient is in a postictal state? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply
1. The patient is incontinent of urine.
2. The patient is in a deep sleep.
3. The patient is confused as to place and time.
4. The patient reports an odd taste in his mouth.
5. The patient is attempting to remove his hospital gown.
2,3
Rationale 1: Incontinence of bowel or bladder is common during a tonic-clonic seizure but is not indicative of a postictal state.
Rationale 2: Deep sleep after the seizure is a finding associated with the postictal state.
Rationale 3: Patients who are in the postictal state may be confused and disoriented.
Rationale 4: An odd taste, specific odor or noise, or other sensory change often heralds a seizure. This is called an aura.
Rationale 5: During complex partial seizures, patients sometimes fumble with or attempt to remove clothing.
Global Rationale: Deep sleep after the seizure is a finding associated with the postictal state. Patients who are in the postictal state may be confused and disoriented. Incontinence of bowel or bladder is common during a tonic-clonic seizure but is not indicative of a postictal state. An odd taste, specific odor or noise, or other sensory change often heralds a seizure. This is called an aura. During complex partial seizures, patients sometimes fumble with or attempt to remove clothing.
You might also like to view...
A nurse returning to practice remarks that delegation is much more regulated and complicated than when she last practiced 20 years ago. What rationale would the nurse manager provide for this change?
1. "The shortage of nurses has been the major reason that there are so many rules to follow when delegating." 2. "Since nursing is trying to move back to the team approach to care delegation has become more important." 3. "The introduction of multiple levels of professional staff members increases need for delegation rules and regulations." 4. "The widespread return to primary nursing makes delegation more risky."
A nurse is preparing to assess a 9-month-old infant admitted to the hospital for further evaluation of an atrial septal defect (ASD). Which should the nurse do first for the cardiac assessment?
a. Percussion b. Palpation c. Auscultation d. History and inspection
MC The nurse is planning to teach a class about dental care to a group of expectant women. The nurse should teach that dental hygiene should begin
A. When the first tooth erupts. B. At birth. C. When the child starts solid food. D. When the child can hold a toothbrush.
Leaders have the final authority on group direction and movement. They control members through rewards and treats and often keep members in the dark about the goals and rationale behind prescribed actions. What type of leadership does this describe?
1. Democratic 2. Patriarchal 3. Socialist 4. Communication structure