A patient without a history of previous seizures experiences two tonicclonic seizures in succession ...

The answer to question 1

Correct Answer: 1, 2, 3, 4
Nursing care of patients during a seizure should first focus on maintaining a patent airway. During a seizure, the tongue may fall back and obstruct the airway, the gag reflex may be depressed, and secretions may pool at the back of the throat. To open and maintain a patent airway the patient should be turned on his or her side. After ensuring the airway is patent, the nurse should protect the patient from harm. Tonicclonic seizures occur without warning, and the patient will have alternating contraction and relaxation of the muscles of all extremities. During the clonic phrase of the seizure, patients are at risk for head injury and fractures of the extremities. After the clonic phase of seizure activity, if needed, oxygen can be administered by face mask. Consciousness returns gradually; it may take hours before the patient is fully aware and alert, and reorientation to person, place, and time can be achieved.

The answer to question 2

Correct Answer: 2, 3, 4, 5
Findings related to disease of or trauma to the lower motor neurons include flaccidity, steppage gait, fasciculations, and muscle atrophy. Muscle tone is increased (spasticity) in disease of the corticospinal motor tract.

The answer to question 3

Correct Answer: 1, 3, 4, 5
Risk factors for the development of neurological problems include occupational hazards, such as exposure to toxic chemicals or materials. Self-care issues related to neurological problems include the use of tobacco and not wearing a helmet when riding a motorcycle or participating in contact sports. Walking the family dog would not increase the risk of developing a neurological problem.

The answer to question 4

Correct Answer: 1, 2, 4, 5
Stimulation of the sympathetic division exerts effects on target organs or tissues including diaphoresis, leading to damp skin; vasoconstriction of skin blood vessels, leading to cold skin; dilation of the bronchioles, leading to deep rapid respirations; and vasoconstriction of arteries, leading to an elevated blood pressure. A heart rate of 68 would be an effect of the parasympathetic division of the autonomic nervous system.

The answer to question 5

Correct Answer: 3
The heel-to-shin test requires the patient to run each heel down each shin, while in a supine position. This technique tests the patient's coordination. Ataxia is the inability to walk or difficulty walking. Graphesthesia is the ability to discriminate a number traced on the palm. Spasticity is an increase in muscle tone associated with disease of the corticospinal motor tract and is not tested with the heel-to-shin technique.

The answer to question 6

Correct Answer: 1, 2, 3, 5
Beta1-receptors are found in the heart, where they regulate the rate and force of contraction. Beta2-receptors are found in receptor cells of the lungs, arteries, liver, and uterus; they help regulate bronchial diameter, arterial diameter, and glycogenesis.

The answer to question 7

Correct Answer: 3
Reflexes are graded using standard criteria from absence (0) to hyperactive (4). 1+ reflexes are weaker than normal. 2+ reflexes are normal. 3+ reflexes are stronger than normal. 4+ reflexes are hyperactive, with sustained clonus.

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