The parents of a pediatric client describe occasional episodes where the client seems to experience a temporary loss of awareness and a blank stare. The nurse suspects which of the following disorders?

Focal awareness seizure

Absence seizure

Transient ischemic attack (TIA)

Tonic clonic seizure

Answer and Explanation

The Correct Answer is B

A. Focal awareness seizure:
Focal awareness seizures (formerly known as simple partial seizures) involve abnormal electrical activity in a specific area of the brain. These seizures typically cause motor symptoms (such as jerking or twitching in one part of the body) or sensory disturbances (like tingling or visual changes), but the person remains fully aware during the episode. The client’s presentation of a temporary loss of awareness and blank stare is more consistent with an absence seizure than a focal awareness seizure, as focal seizures do not cause a loss of consciousness.

B. Absence seizure:
Absence seizures are a type of generalized seizure often seen in children. These seizures are characterized by a sudden, brief loss of awareness, typically lasting only a few seconds. During the episode, the child may exhibit a blank stare and seem unresponsive, often without any noticeable physical movements. These seizures are often mistaken for daydreaming or inattention, but they can be diagnosed with an EEG (electroencephalogram) showing characteristic patterns. This description matches the parents’ observations of occasional episodes of loss of awareness and a blank stare.

C. Transient ischemic attack (TIA):
A TIA, also known as a mini-stroke, involves temporary neurological symptoms due to a brief disruption in blood flow to the brain. However, TIAs usually last longer than the brief episodes of loss of awareness described in this case, and they are more likely to cause focal neurological not just a transient loss of awareness. Additionally, TIAs are much less common in children and are usually associated with other risk factors like cardiovascular disease or clotting disorders.

D. Tonic clonic seizure:
Tonic-clonic seizures (formerly known as grand mal seizures) involve generalized shaking or convulsions, loss of consciousness, and can last from 1 to 3 minutes. These seizures are usually much more dramatic and prolonged compared to the brief, absence-like episodes described here. While they do involve a loss of awareness, the physical manifestations (muscle stiffening and jerking) and duration are distinctively different from the blank stare and brief loss of awareness typical of an absence seizure.

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Correct Answer is C

Explanation

A. Auscultate the client’s apical pulse for a full minute:
While auscultating the apical pulse is important for certain cardiovascular conditions, it is not the primary action needed before administering sublingual nitroglycerin. The nurse's main priority is to assess the patient's blood pressure, as nitroglycerin can cause significant hypotension (a drop in blood pressure), and it is important to ensure the patient’s blood pressure is adequate before administration. If the blood pressure is too low, nitroglycerin should not be given.

B. Advise the client that vomiting is a primary side effect:
Vomiting is not a primary or common side effect of sublingual nitroglycerin. Nitroglycerin is more likely to cause headaches, dizziness, flushing, and hypotension. While it’s helpful to inform the patient about possible side effects, advising them that vomiting is a primary side effect could cause unnecessary concern or confusion.

C. Check the client’s blood pressure:
This is the correct action. Nitroglycerin works by dilating blood vessels, which can lower blood pressure. Before administering sublingual nitroglycerin, it is essential to check the client's blood pressure. If the client is hypotensive or has low blood pressure, nitroglycerin should be withheld, as it could further decrease blood pressure and worsen the patient’s condition. This is the priority nursing action to ensure the patient’s safety.

D. Obtain a STAT chest X-ray:
Obtaining a chest X-ray is not a priority action for a client with unstable angina before administering nitroglycerin. Chest X-rays are more useful for diagnosing conditions like pneumonia, pneumothorax, or other structural issues of the chest, but they are not immediately needed in the management of unstable angina. The most immediate concern is assessing the patient’s blood pressure before administering nitroglycerin.

A. 2+ pedal edema bilaterally B. Blood pressure at 107/82 C. Urine output of 460 mL in 24 hours D. Disorientation

Correct Answer is D

Explanation

A. 2+ pedal edema bilaterally:
While 2+ pedal edema (a mild level of swelling in the feet and ankles) is concerning, it is not an immediate emergency in the context of hyponatremia. Edema can be seen in various conditions, including fluid retention associated with hyponatremia, but it does not require urgent intervention unless it is severe or worsening. This finding would warrant monitoring but does not require immediate action.

B. Blood pressure at 107/82:
A blood pressure reading of 107/82 mmHg is within normal limits, although on the lower end of the spectrum. This is not a concerning finding in this case and does not suggest a need for immediate intervention. The nurse should continue to monitor the client, but this blood pressure reading alone is not an emergency.
C. Urine output of 460 mL in 24 hours:
A urine output of 460 mL in 24 hours is low, indicating oliguria (decreased urine output), which can occur in cases of hyponatremia due to fluid retention. However, unless the urine output is worsening or associated with other signs of acute kidney injury or severe fluid overload, this finding alone does not require immediate intervention. It is something that should be monitored and further investigated.

D. Disorientation:
Disorientation in the elderly client with hyponatremia is a critical finding that requires immediate intervention. Hyponatremia can lead to cerebral edema (brain swelling), which results in altered mental status, including confusion, disorientation, or seizures. These symptoms indicate that the hyponatremia may be severe enough to affect neurological function and requires prompt correction to avoid further complications, such as coma or permanent brain damage. Immediate intervention to address the underlying cause of the hyponatremia and restore sodium balance is crucial.

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The parents of a pediatric client describe occasional episodes where the client seems to experience a temporary loss of awareness and a blank stare. The nurse suspects which of the following disorders?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring who presented with unstable angina. Before giving the client, a dose of sublingual nitroglycerin, which action should the nurse take?

Correct Answer is C

Explanation

The nurse is assessing an elderly client admitted for hyponatremia. Which of the following findings requires immediate intervention?

Correct Answer is D

Explanation

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