A patient is admitted to the Emergency Department (ED). The nurse documents "postictal upon transfer" as evidenced by which observation?
Abnormal sensory sensations including tingling of the skin
Yellowing of the skin
Severe itching of the eyes
Is in a drowsy confused state after a seizure
The Correct Answer is D
A. Abnormal sensory sensations such as tingling may be associated with the aura phase of a seizure but are not typically observed postictally.
B. Yellowing of the skin is usually indicative of jaundice, unrelated to seizure activity or the postictal state.
C. Itching of the eyes is unrelated to seizure activity and would not typically be documented in the context of postictal observations.
D. The postictal state is characterized by drowsiness, confusion, and other altered mental statuses that follow a seizure. This period can vary in duration depending on the patient and seizure type.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. 1:1 observation may be excessive unless the behavior is persistent and unmanageable.
B. Pointing out the behavior as unacceptable provides immediate feedback and helps the patient understand social boundaries, which can be challenging post-brain injury. This approach is direct and respectful, focusing on redirection rather than punishment.
C. Asking why may not be effective, as the patient may lack insight into their behavior due to the brain injury.
D. Having the patient return to their room could seem punitive and does not address the need for behavior modification.
Correct Answer is A
Explanation
A. Timolol is a beta-blocker that can be absorbed systemically, leading to side effects such as bradycardia and hypotension, which require monitoring.
B. Tachycardia and dry cough are not common side effects of timolol; dry cough is more associated with ACE inhibitors.
C. Scleral injection and tearing are not common side effects and are not expected with timolol use.
D. Changes in eye pigmentation are more commonly seen with prostaglandin analogs, not with beta-blockers like timolol.
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