NCLEX SEIZURES

1. The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last?

1. Maintain a patent airway

2. Record the seizure activity observed

3. Ease the client to the floor

4. Obtain vital signs

Correct Answer: 3, 1, 4, 2
Rationale: The first priority is safety—easing the client to the floor prevents injury. Then maintain airway patency. After the seizure ends, obtain vital signs and document the seizure activity.

Which finding will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure?

1. Jerking in one extremity that spreads gradually to adjacent areas

2. Vacant staring and abruptly ceasing all activity

3. Facial grimaces, patting motions, and lip smacking

4. Loss of consciousness, body stiffening, and violent muscle contractions

Correct Answer: 4
Rationale: Tonic-clonic seizures involve sudden loss of consciousness followed by tonic (stiffening) and clonic (jerking) muscle activity.

It is the night before a client is to have a CT scan of the head without contrast. What should the nurse tell the client?

1. “You must shampoo your hair tonight to remove all oil and dirt.”

2. “You may drink fluids until midnight, but after that, drink nothing until the scan is completed.”

3. “You will have some hair shaved to attach the small electrode to your scalp.”

4. “You will need to hold your head very still during the examination.”

Correct Answer: 4
Rationale: During a CT scan, movement can blur the images, so clients are instructed to remain still. Fasting is unnecessary for a non-contrast scan.

The client will have an electroencephalogram (EEG) in the morning. What should the nurse instruct the client to eat for breakfast?

1. No food or fluids

2. Only coffee or tea if needed

3. A full breakfast as desired without coffee, tea, or energy drinks

4. A liquid breakfast of fruit juice, oatmeal, or smoothie

Correct Answer: 3
Rationale: Clients can eat a normal breakfast but must avoid caffeine, which may affect brain activity readings.

The client is scheduled to receive phenytoin through a nasogastric tube and has a tube-feeding supplement running continuously. What should the nurse do?

1. Elevate the head of the bed to 60 degrees

2. Draw blood to determine the phenytoin level after the morning dose

3. Stop the tube feeding 1 hour before and after giving phenytoin

4. Flush the NGT with 150 mL of water before and after giving phenytoin

Correct Answer: 3
Rationale: Tube feedings can interfere with phenytoin absorption. Stopping the feeding before and after improves medication effectiveness.

Which instruction should the nurse include in teaching a client who is going home with a prescription for gabapentin?

1. Take all the medication until it is gone

2. Notify the HCP if vision changes occur

3. Store gabapentin in the refrigerator

4. Take gabapentin with an antacid to protect against ulcers

Correct Answer: 2
Rationale: Vision changes can be a side effect of gabapentin and should be reported. It does not need to be refrigerated, and it should not be taken with antacids.

What is the priority nursing intervention in the postictal phase of a seizure?

1. Reorient the client to time, person, and place

2. Determine the client’s level of sleepiness

3. Assess the client’s breathing pattern

4. Position the client comfortably

Correct Answer: 3
Rationale: Airway and breathing are the first priorities after a seizure. The nurse must ensure the client is breathing adequately postictally.

Which intervention is most effective in minimizing the risk of seizure activity during diagnostic studies?

1. Maintain the client on bed rest

2. Administer a sedative as prescribed

3. Close the door to minimize stimulation

4. Administer carbamazepine 200 mg PO twice daily

Correct Answer: 4
Rationale: Carbamazepine is an anticonvulsant that helps prevent seizures. Preventive medication is the most effective method.

What assessments should be documented at the beginning of the ictal phase?

1. Heart rate, respirations, pulse oximeter, blood pressure

2. Last dose of anticonvulsant and circumstances

3. Type of aura (visual, auditory, olfactory)

4. Movement of the head/eyes and muscle rigidity

Correct Answer: 4
Rationale: Observing and documenting movement patterns during a seizure helps identify the seizure focus and guide treatment.

The nurse is assessing a client in the postictal phase of a generalized tonic-clonic seizure. What symptom is expected?

1. Drowsiness

2. Inability to move

3. Paresthesia

4. Hypotension

Correct Answer: 1
Rationale: After a seizure, clients are often drowsy and confused. This is a normal part of the postictal phase.

The HCP has prescribed phenytoin sodium. What should the nurse explain about stopping the drug suddenly?

1. Physical dependency may develop

2. Status epilepticus may occur

3. A hypoglycemic reaction is likely

4. Heart block can happen

Correct Answer: 2
Rationale: Abrupt withdrawal of anticonvulsants like phenytoin can cause status epilepticus, a life-threatening emergency.

The nurse is teaching a client with seizures to recognize an aura. What should the nurse instruct the client to notice?

1. A postictal state of amnesia

2. A hallucination during the seizure

3. A symptom that occurs just before a seizure

4. A feeling of relaxation as the seizure subsides

Correct Answer: 3
Rationale: An aura is a warning sign that a seizure is about to occur and may include unusual sensations or emotions.

Which statement by a client on topiramate indicates correct understanding?

1. “I will take the medicine before bed.”

2. “I will drink six to eight glasses of water daily.”

3. “I will eat plenty of fresh fruits.”

4. “I will take the medicine with a meal or snack.”

Correct Answer: 2
Rationale: Topiramate increases the risk of kidney stones. Adequate hydration reduces this risk.

Which clinical manifestation is a typical reaction to long-term phenytoin sodium therapy?

1. Weight gain

2. Insomnia

3. Excessive growth of gum tissue

4. Deteriorating eyesight

Correct Answer: 3
Rationale: Gingival hyperplasia (gum overgrowth) is a well-known side effect of long-term phenytoin use.

A 21-year-old female client takes clonazepam. What should the nurse ask about? (Select all that apply.)

1. Seizure activity

2. Pregnancy status

3. Alcohol use

4. Cigarette smoking

5. Caffeine/sugary drink intake

Correct Answer: 1, 2, 3
Rationale: Clonazepam is teratogenic and can cause sedation when combined with alcohol. Assessing seizure control is essential. Smoking and caffeine are less relevant for this drug.