HESI Case Studies–Medical/Surgical-Seizure Disorder (Alanna Milstein)

1. Prioritize the nursing actions in order from first action through last action
1. Safely move the client to the floor
2. Push the furniture away from the client
3. Remove people from the waiting room
4. Assess the client’s blood pressure
2. What action should the nurse implement next?
Note the time, duration, and type of seizure
3. Which intervention should the nurse implement?
Turn the client to the side, and allow him to sleep
4. Which of the medical history question(s) should the nurse ask Alanna to determine why the seizure activity started? (Select all)
-“Have you ever had any type of head injury?”
-“Do you have a history of drinking alcohol?”
5. Which response by the nurse is correct?
“It is a visual or auditory warning that the seizure is about to start.”
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6. Which action should the nurse include in preparing Alanna for the EEG?
Instruct the client to refrain from consuming caffeine prior to the EEG
7. Which statement by the nurse is the best response?
“The test will rule out many possible causes of seizures”
8. Which statement indicates that Alanna understands the client teaching?
“I must brush and floss my teeth after every meal.”
9. Which instruction should the nurse include in the teaching session?
Avoid hazardous tasks until the drug has been regulated
10. Which response by the nurse is most therapeutic?
“This is all new to you, and you must be frightened. Let’s talk for a while.”
11. The nurse’s response should be based on which scientific rationale?
Epilepsy does not prevent women from having children
12. Which health promotion activity should the nurse discuss with Alanna?
Learn to identify seizure triggers
13. How should the nurse respond?
“Your menstrual cycle can cause seizure activity due to hormone levels.”
14. Which statement by Alanna indicates that teaching provided by the nurse has been effective?
“I will carry a Medic Alert band at all times.”
15. Which statement reflects that the nurse understands the legal ramifications of the employer’s action?
“According to the Americans with Disabilities Act, your employer cannot terminate you.”
16. How should the nurse respond?
“You need to contact the Department of Transportation to find out the state laws.”
17. Which statement is the nurse’s best response?
“Someone who knows what to do if you have a seizure should be with you.”
18. How should the nurse respond?
“It really depends on how well your epilepsy is controlled.”
19. If the nurse believes in the ethical principle of veracity for the client, how should the nurse respond?
“You should tell him the truth on the first date so he will know.”
20. Which intervention should the nurse implement first?
Ensure suction equipment is at the bedside
21. Which action should the nurse implement?
Dilute the medication and flush the tubing before and after with normal saline
22. Which question is most important for the nurse to ask Alanna?
“Have you been taking your medication regularly?”
23. Which intervention should the nurse implement?
Pad and elevate the side rails of Alanna’s bed
24. How should the nurse respond?
“The most important thing is to keep her from injuring herself.”
25. Which statement reflects that the nurse is sensitive to Alanna’s cultural needs?
“Tell me about the type of Jewish teachings you practice.”
26. What action should the nurse take?
Return the tray provided by the hospital and ask the parents if they would like to take the meal they provided to Alanna’s room
27. Which action should the nurse include when providing discharge teaching regarding the new medication?
Discuss with the client the importance of having liver function tests while on this medication
28. Which client teaching goal is most important to determine Alanna’s understanding?
Describe five strategies to prevent seizure activity
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