A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds. What would the nurse expect to assess after a generalized tonic-clonic seizure?

Sleepiness

Restlessness

Anxiety

Nausea

Answer and Explanation

The Correct Answer is A

A.   This is a common postictal manifestation after a generalized tonic-clonic seizure. Following the intense muscle activity and convulsions during the seizure, the child may experience exhaustion and feel sleepy. The postictal state often involves a period of drowsiness or even brief loss of consciousness.
B.   Restlessness is less likely to be observed immediately after a generalized tonic-clonic seizure. Instead, the child is more likely to exhibit fatigue and lethargy as the body recovers from the seizure activity.

C.   Anxiety may occur during or immediately after the seizure due to the sudden and frightening nature of the event. However, in the postictal period, anxiety typically diminishes as the child becomes more oriented and aware of their surroundings.
D.   Nausea is not a typical postictal manifestation after a generalized tonic-clonic seizure. While some individuals may experience nausea or vomiting during the seizure (ictal phase), it is less common in the postictal period.

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Correct Answer is B

Explanation

B. The most serious complication associated with skeletal traction is osteomyelitis, an infection that involves the bone. This condition can occur when organisms gain access to the bone either systemically or through the openings created by the metal pins or wires used in the traction.

A. Increased blood pressure can occur for various reasons but it is not the most serious complication associated with skeletal traction.

C. A decrease in urine output could indicate systemic infection which is a late feature of osteomyelitis and therefore, not the earliest to monitor.

D. Changes in appetite can occur in response to pain or stress but they are not typically the most serious complication associated with skeletal traction.

A. The presence of protein in the urine B. Signs of increased intracranial pressure C. Signs of hyperglycemia D. Signs of a bacterial infection

Correct Answer is B

Explanation

B. Reye's syndrome is characterized by swelling of the brain (cerebral edema), which can lead to increased intracranial pressure (ICP). Monitoring for signs of increased ICP, such as changes in level of consciousness, headache, vomiting, and altered pupil size and reactivity, is crucial for early detection and intervention to prevent neurological deterioration.

A. Reye's syndrome primarily affects the liver and brain, leading to liver dysfunction and encephalopathy. While renal involvement can occur in some cases, the priority complication typically relates to liver dysfunction and neurological manifestations rather than renal impairment.

C. Hyperglycemia may be present due to liver dysfunction and altered glucose metabolism, but it is not the primary concern compared to neurological complications and hepatic failure.

D. Reye's syndrome is not caused by a bacterial infection; it is typically associated with viral illnesses, particularly influenza and varicella (chickenpox).

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A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds. What would the nurse expect to assess after a generalized tonic-clonic seizure?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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