Meet the Client: Alanna Milstein

Alanna Milstein, a young single woman, who is Jewish is referred to a neurologist by her family healthcare provider because she had two probable seizures during the last 2 months.

Alanna, a sales clerk in a department store, has been attending the local university part-time for the last 5 years majoring in business. She lives with a roommate in a small apartment about 20 miles from her parents' home. Alanna, her family, and roommate are very active in the Shalom Synagogue. Alanna decides to come to the appointment with the neurologist by herself and is sitting in the neurologist's waiting room.

An Emergency Occurs

A man sitting across from Alanna starts having a seizure. His entire body is rigid, his arms and legs are contracting and relaxing, and he is making guttural sounds. Alanna yells for the nurse, who immediately comes into the waiting room.1.

Which action should the nurse implement first?

A)Push the furniture away from the client.

INCORRECTThe nurse does need to protect the client from injury so moving furniture will help ensure that the client does not hit something accidentally. However, this is not the first intervention.

B)Remove people from the waiting room.

INCORRECTThe nurse should shield the client from onlookers but this is not the most important action to implement.

C)Assess the client's blood pressure.

INCORRECTAssessment is important but when the client is having a seizure the nurse should not touch the person. Assessment will be completed after the seizure activity has ended.

D)Safely move the client to the floor.

CORRECTThe client in the chair must be brought safely to the floor so that he will have room to move his extremities and not injure himself during the seizure. It is not safe to leave a client having a generalized tonic-clonic seizure in a chair.

After initial interventions are implemented, the man continues to have a tonic-clonic seizure.

2.

What action should the nurse implement next?

A)Insert an oral airway into the client's mouth.

INCORRECTOnce the seizure has started the nurse should not attempt to put anything in the mouth. The jaws are clenched and attempting to insert an oral airway could injure the client.

B)Determine if the client is incontinent of urine.

INCORRECTThe nurse should assess for bowel and bladder incontinence but this is not the most immediate priority.

C)Note the time, duration, and type of seizure.

CORRECTAccurate assessment by the nurse during the seizure provides important data used in determining the area in which focal activity originates, the area of the brain involved, and the type of seizure. It is important to document whether the beginning of the seizure was observed.

D)Notify the neurologist of the client's seizure.

INCORRECTThe neurologist must be notified of the seizure but this is not the nurse's next action.

After the man's seizure activity stops he is moved to a private room. The client had a 3 minute seizure, has no apparent injuries and is oriented to name, place, and time, but is very lethargic.

3.

Which intervention should the nurse implement?

A)Perform a complete neurological assessment.

INCORRECTThe nurse should make sure the client is breathing and has no injuries. There is no need to perform a complete neurological assessment.

B)Transfer the client to the emergency department.

INCORRECTAs long as the client has stopped seizing, is oriented, and has not sustained any injuries, there is no need to transfer the client to the emergency department.

C)Turn him to the side and allow the client to sleep.

CORRECTDuring the postictal phase the client is very tired and should be allowed to rest quietly and sleep; placing the client on the side will help maintain a patent airway and prevent aspiration.

D)Interview the client to find out what caused the seizure.

INCORRECTInterviewing the client can wait until the client has recovered from the seizure. Once the gentleman with the seizure is taken to the private room, the other people are brought back into the waiting room. Alanna sits down and after 20 minutes is called back to the neurologist's office.

Assessment

The nurse asks Alanna why she has been referred. Alanna reports that 2 weeks ago her roommate found her passed out on the floor. Alanna states she could not remember what happened but thought it might be because she had not been eating right. Then, last week Alanna's roommate found her making unusual sounds and noticed that her arms and legs were jerking. At that time she was taken to the emergency department. She has her emergency room records and her past history medical records from her family healthcare provider.

4.

To help determine why the seizure activity started, which question should the nurse ask Alanna?

A)"Have you ever had any type of head injury?"

CORRECTHead trauma is a possible cause for the new onset of seizure activity.

B)"Are you currently taking any type of illegal drugs?"

INCORRECTIllegal drugs are not a typical cause for seizure activity.

C)"Is there any chance that you may be pregnant?"

INCORRECTPregnancy alone does not increase the client's risk for a seizure unless the woman is diagnosed with eclampsia.

D)"Does anyone in your family have seizure disorders?"

INCORRECTSeizure activity is not hereditary.

Alanna responds to the nurse's questions, and then tells the nurse that someone has been talking to her about seizures and asked her if she had aura with her seizure. She asks the nurse, "What is an aura?"

5.

Which response by the nurse is correct?

A)"It is a visual or auditory warning that the seizure is about to start."

CORRECTAn aura is a visual, auditory, or olfactory occurrence that occurs prior to a seizure which warns the client that the seizure is about to occur. The aura often allows time for the client to fall to the floor or find a safe place to have the seizure.

B)"Auras occur when you are physically and physiologically exhausted."

INCORRECTAn aura is not dependent on the client being physically or physiologically exhausted.

C)"If you had an aura you would know what it is."

INCORRECTThis is not a therapeutic response. The nurse is not addressing the client's question.

D)"Auras do not occur with the type of seizures that you are having."

INCORRECTThis is incorrect information.

Alanna tells the nurse she remembers hearing a buzzing sound, and then the next thing she knew someone was waking her up. The neurologist comes into the room and completes Alanna's history and physical along with the nurse. With Alanna's history, the neurologist thinks that Alanna has had seizure activity and wants to determine exactly what is causing the new onset of seizure activity.

Diagnostic Tests

The neurologist schedules Alanna for an electroencephalogram (EEG) and a magnetic resonance image (MRI) to help evaluate Alanna's seizure disorder. The nurse discusses the tests with Alanna.

6.

Which action should the nurse include in preparing Alanna for the EEG?

A)Advise the client not to eat anything 12 hours prior to the procedure.

INCORRECTMeals are not withheld because an altered blood glucose level can cause changes in brain wave patterns. Caffeine-containing foods should be withheld since they will stimulate brain waves.

B)Instruct the client to refrain from consuming caffeine prior to the EEG.

CORRECTIngestion of caffeine will cause a stimulating effect to the brain.

C)Explain there will be some discomfort during the procedure.

INCORRECTThe test is painless and is performed while lying on a bed.

D)Determine if Alanna has any allergies to iodine or shellfish.

INCORRECTThis diagnostic test does not require the injection of any type of dye or contrast medium.

Alanna appears overwhelmed with all the information the neurologist discussed with her. She asks the nurse, "I don't understand why the neurologist is ordering an MRI."

7.

Which statement by the nurse is the best response?

A)"The test will rule out many possible causes of seizures."

CORRECTAn MRI can determine the presence of a tumor, congenital lesions, edema, infarct, hemorrhage, arteriovenous malformation, or a structural deviation that may be the cause of the seizures.

B)"An MRI can help determine the focal origin of the seizure."

INCORRECTA complete neurological examination can help determine the focal neurological deficit or the focus or origin of the seizure activity.

C)"This test will identify elevated protein levels in the brain."

INCORRECTA lumbar puncture will help determine if there are elevated protein levels in the cerebrospinal fluid; there is not a test that identifies protein levels in the brain tissue.

D)"It will confirm the seizure diagnosis and localize the lesion."

INCORRECTThe electroencephalogram helps confirm the diagnosis and localize the lesion.

Medication Teaching

The neurologist informs Alanna that no brain tumor, infection, or trauma was found but she did have seizure brain wave activity during the EEG. This brain activity is indicative of Epilepsy. The neurologist prescribes phenytoin (Dilantin), an anticonvulsant, to help prevent the seizure activity. The clinic nurse teaches Alanna about the medication, its side effects, and the need to take it every day.

8.

Which statement indicates that Alanna understands the client teaching?

A)"I must brush and floss my teeth after every meal."

CORRECTGingival hyperplasia is a common occurrence in clients taking Dilantin. Thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care are essential to prevent this complication.

B)"I will have to check my medication level daily."

INCORRECTA serum (venipuncture) Dilantin level is checked monthly at first then every 6 months once a therapeutic level is attained.

C)"My stool may be clay-colored while taking this drug."

INCORRECTClay-colored stool indicates liver problems which should be reported to the healthcare provider.

D)"I will not have seizures since I am on this medication."

INCORRECTMedication does not ensure that the client will not have seizures. In some instances medication dosage may need to be adjusted or the client may need another medication.

The nurse continues to teach Alanna about the newly prescribed anticonvulsant medication.

9.

Which instruction should the nurse include in the teaching session?

A)Decrease alcohol intake while taking this medication.

INCORRECTThe client should not drink any type of alcohol when taking anticonvulsants.

B)Take the medication with milk or milk products.

INCORRECTMilk or milk products will decrease the absorption of the medication in the stomach.

C)Notify the office if experiencing muscle uncoordination.

INCORRECTAnticonvulsant drugs may at first cause muscle uncoordination but the effects usually disappear after continued therapy.

D)Avoid hazardous tasks until the drug has been regulated.

CORRECTThese medications may cause drowsiness, decreased mental alertness, and dizziness at first. With continued therapy these symptoms usually disappear or the dose may have to be changed.

Therapeutic Communication

During the teaching session, Alanna shares with the nurse that she is very scared because she really doesn't remember having the seizure. She states that she had never seen someone with a seizure until the other day in the neurologist's office. Illness has never been part of her life and she doesn't feel sick now.

10.

Which response by the nurse is most therapeutic?

A)"You should contact the Epilepsy Foundation. I think it will help."

INCORRECTReferrals are indicated but Alanna is expressing feelings of being overwhelmed. Therefore a referral is not the most therapeutic response at this time.

B)"This is all new to you, and you must be frightened. Let's talk for awhile."

CORRECTThe nurse acknowledges Alanna's feelings and encourages her to continue to ventilate her feelings.

C)"Because you don't feel bad doesn't mean you won't have a seizure."

INCORRECTWhile this response teaches Alanna more about the disease, it does not address Alanna's fears.

D)"I know seeing someone having a seizure is a frightening experience."

INCORRECTWhile this statement acknowledges Alanna's fear at seeing the seizure, it is not the most therapeutic response.

Alanna shares that she is worried about being able to have children. She doesn't have a boyfriend right now but someday wants to get married and raise a family.

11.

The nurse's response should be based on which scientific rationale?

A)Research shows that women with epilepsy have a more difficult time conceiving.

INCORRECTThere is no research that reports that women with a seizure disorder cannot get pregnant.

B)Anticonvulsant therapy is contraindicated in pregnancy.

INCORRECTAlthough some anticonvulsants cause fetal malformations, there are anticonvulsants that can be safely used during pregnancy.

C)Epilepsy does not prevent women from having children.

CORRECTAlanna will need preconception counseling when considering child birth. She will require special care and guidance before, during, and after pregnancy.

D)Genetic counseling is needed for women with epilepsy.

INCORRECTThere is no data supporting a strong genetic component for epilepsy. Epilepsy may be idiopathic, secondary to birth injuries, infection, vascular abnormalities, or trauma.

Health Promotion

Education is the key to treating epilepsy. The office nurse teaches Alanna about how to reduce the incidence of seizure activity and how to promote safety during a seizure.

12.

Which health promotion activity should the nurse discuss with Alanna?

A)Take tub baths rather than showers.

INCORRECTShowers, rather than tub baths are safer because showers reduce the risk of drowning if a seizure occurs.

B)Be sure to exercise outside rather than in a gym.

INCORRECTExercise should be done in moderation in a temperature-controlled environment to avoid excessive heat.

C)Learn to identify seizure triggers.

CORRECTFactors that may trigger seizures are abrupt withdrawal from medication, constipation, fatigue, fever, and sounds and sights such as television, flashing videos, and computer screens.

D)Take an anticonvulsant when an aura occurs.

INCORRECTThe client should take anticonvulsant medication daily to obtain a therapeutic serum level to help prevent seizure activity. There is no anticonvulsant that can be taken when an aura occurs that will prevent the seizure.

Alanna tells the nurse that she was on her "period" or getting ready to start her "period" both times she had a seizure. She shares with the nurse she is really worried about having a seizure the next time she menstruates.

13.

How should the nurse respond?

A)"You are concerned about having a seizure when you start your period."

INCORRECTRestating, a therapeutic communication technique, is not the best response in this situation, when the client has clearly expressed her concern and is seeking information.

B)"Are you currently taking any type of birth control pill or using the patch?"

INCORRECTBirth control pills and patches are not known to cause or affect seizure activity.

C)"Your menstrual cycle can cause seizure activity due to hormone levels."

CORRECTThe onset of menstruation can cause seizure activity due to increased hormone levels that alter the excitability of neurons in the cerebral cortex. The client should be instructed to keep a record to determine if this pattern continues.

D)"The menstrual cycle does not usually affect your seizure activity."

INCORRECTThis information is incorrect.

14.

Which statement by Alanna indicates that teaching provided by the nurse has been effective?

A)"I should move back home with my parents."

INCORRECTThis statement indicates that Alanna does not think she can live independently. Therefore more teaching is needed to empower her to accept her seizure disorder and live a productive life for a 23-year-old woman.

B)"I will carry a Medic Alert band at all times."

CORRECTAlanna should carry a band or card at all times so her medical condition will be easy to identify.

C)"I do not think that I need to go to any support groups."

INCORRECTThe nurse should encourage Alanna to attend support groups which help clients have a healthy adaptation to the chronic condition.

D)"It is important for my family to get checked for epilepsy."

INCORRECTEpilepsy does not have a strong genetic component and is no more prevalent in the Jewish population than any other culture.

Legal Issues

Two months after being diagnosed with the seizure disorder, Alanna calls the office and tells the nurse that her job's supervisor has informed her that she is going to be let go because of her seizure disorder. Alanna is very upset and tells the nurse that she has been working at the same department store since she was 18-years-old.

15.

Which statement reflects that the nurse understands the legal ramifications of the employer's action?

A)"The Epilepsy Foundation of America will help you keep your job."

INCORRECTThis organization has a training and placement service for individuals who need jobs but has no legal authority.

B)"I was afraid this might happen. Legally employers do not have to let you work."

INCORRECTEmployees have legal rights according to the federal government just like the employer has legal rights.

C)"You should take a copy of your medical records to your employer's personnel office."

INCORRECTThe personnel office does not need a copy of Alanna's medical records.

D)"According to the Americans with Disabilities Act, your employer cannot terminate you."

CORRECTThe 1990 Americans with Disabilities Act states that employers must evaluate an employee's ability to perform the job and may not discriminate on the basis of a disability.

While talking on the phone, Alanna asks the nurse about driving her car. She states that she has not been driving due to the medications but hasn't had a seizure in 2 months and is not drowsy. She asks if she can start driving her car.

16.

How should the nurse respond?

A)"You need to contact the Department of Transportation to find out the state laws."

CORRECTEach state has laws concerning individuals with a seizure disorder having a driver's license. Some states will allow a driver's license after being seizure free for 6 months to 2 years. Many states require letters from the physician or nurse practitioner.

B)"You should not drive your car. Can't you keep taking the bus or train?"

INCORRECTThis response does not give Alanna any hope of ever being independent enough to drive a car and may not be correct information.

C)"I don't think you would want to be responsible for causing a car accident."

INCORRECTThis is a negative statement and does not address Alanna's question.

D)"I want you to make an appointment to come see me and we can talk."

INCORRECTThe nurse can effectively respond to this question over the phone.

Support Group Meeting

Alanna, her roommate, and her parents decide to attend an epileptic support group meeting that is held monthly at the local hospital. The topic for tonight is leisure activity and living with epilepsy. A clinical nurse specialist is the guest speaker for the group. One of the group members asks the nurse, "Is it okay for me to swim at the local YMCA?"

17.

Which statement is the nurse's best response?

A)"Research shows that cold water causes seizures more than warm water."

INCORRECTThere is no research that shows the temperature of water causes seizures.

B)"Someone should be with you that knows what to do if you have a seizure."

CORRECTThe Epilepsy Foundation states there is no reason why people with epilepsy should not participate in swimming as a leisure activity; however it is recommended that a swimming partner be present who is knowledgeable about what to do during a seizure.

C)"Before attempting to go swimming, you should consult with your healthcare provider."

INCORRECTThere is no need to discuss this activity with the healthcare provider. However, if the client has uncontrollable seizures then swimming should be discouraged.

D)"Swimming is one activity that people with epilepsy should plan to avoid."

INCORRECTSwimming does not typically need to be excluded from leisure activity.

Another member of the group asks if there are any activities that should be avoided.

18.

How should the nurse respond?

A)"Mountain climbing is an example of an activity to avoid."

INCORRECTWhile this activity is potentially dangerous, all people with epilepsy do not need to avoid mountain climbing. It is essential, however, that the safety of everyone involved is considered.

B)"It really depends on how well your epilepsy is controlled."

CORRECTIf seizures are well-controlled there are no specific contraindications to any activity. However, if seizures are still occurring it is probably advisable to avoid some sports and activities.

C)"As long as safety gear is worn you can do any activity."

INCORRECTSafety gear is important but does not ensure that the person will not be injured or die during a seizure.

D)"Epileptics should not participate in any contact sports."

INCORRECTGenerally, people with epilepsy are able to take part in contact sports such as rugby, football, and hockey as long as normal safeguards are followed. Boxing should be avoided.

The group leader shares that participation in any leisure activity requires weighing the risks against the benefits that the activity provides. Safety of the individual with epilepsy as well as the others participating in the activity is of the utmost importance.

When the group meeting is over, Alanna privately asks the nurse, "When is the best time to tell a potential boyfriend I have a seizure disorder?"

19.

If the nurse believes in the ethical principle of veracity for the client, how should the nurse respond?

A)"I would recommend waiting until it becomes more serious."

INCORRECTThis response does not reflect veracity.

B)"That is a hard question to answer. I am not sure I know the right answer."

INCORRECTThis response avoids the client's question.

C)"You should tell him the truth on the first date so he will know."

CORRECTVeracity is truth-telling, and is reflected by this response.

D)"You are worried about how to tell your boyfriend you have epilepsy?"

INCORRECTThis is a therapeutic response addressing her feelings but does not reflect the ethical principle of veracity.

An Emergency Occurs

Three weeks after the phone call to the office nurse, Alanna is transported to the emergency room by an ambulance, accompanied by her roommate. Her roommate states, "She was watching television and had a seizure. As soon as the first seizure stopped, she started having another seizure, so I called 911." Alanna is lying on the stretcher with her eyes closed but there is no seizure activity at this time.

20.

Which intervention should the nurse implement first?

A)Assess the client's vital signs.

INCORRECTThe nurse will need to assess the client's vital signs but in this situation this is not the first intervention.

B)Obtain a serum phenytoin (Dilantin) level.

INCORRECTObtaining a serum Dilantin level is indicated but there is a more immediate priority.

C)Ensure suction equipment is at the bedside.

CORRECTThe client will be very tired and want to sleep after a seizure and maintaining a patent airway is priority. Suction equipment should be available in case the client aspirates or starts choking. Remember Maslow's Hierarchy of Needs. Airway is always first.

D)Apply a cardiac telemetry monitor.

INCORRECTMonitoring the client's cardiac rhythm is indicated but it is not the priority intervention.

Alanna's serum phenytoin (Dilantin) level is 7 mcg/ml. She has intravenous fluids of 5% Dextrose in Water (D5W) infusing at 100 ml/hour in the left forearm. The emergency room physician prescribes phenytoin (Dilantin) 25 mg intravenous push.

21.

Which action should the nurse implement?

A)Question the prescription since 7 mcg/ml is above the therapeutic level.

INCORRECTThe therapeutic Dilantin level is 10 to 20 mcg/ml.

B)Dilute the medication and flush the tubing before and after with normal saline.

CORRECTDilantin is not compatible with any fluid except normal saline; the nurse should flush the IV before and after with normal saline only.

C)Administer the medication undiluted in the port closest to the intravenous site.

INCORRECTAdministering Dilantin in this manner may result in a life-threatening complication.

D)Determine the time when Alanna took the last oral dose of her Dilantin.

INCORRECTThis information will not affect the administration of this medication.

An hour later, Alanna is awake and alert. She does not remember what happened but remembers hearing a buzzing sound. The next thing she remembers is waking up in the emergency room.

22.

Which question is most important for the nurse to ask Alanna?

A)"Why did you quit taking your medication?"

INCORRECTThis question may be perceived as judgmental and challenging, and may be based on an inaccurate assumption. This will not help develop a therapeutic relationship between Alanna and the nurse.

B)"Have you been taking your medication regularly?"

CORRECTSince the therapeutic Dilantin level is low, the nurse may infer that Alanna has not been taking her medication as prescribed. However, the nurse needs to clarify this inference, and then determine the reason before taking further action. It is important to question the client in a non-threatening manner to obtain the needed information, which helps establish a therapeutic relationship.

C)"Were you under any type of stress the last week?"

INCORRECTStress may trigger a seizure but another question is more important.

D)"Are you currently on or just finished your period?"

INCORRECTThe menstrual cycle may trigger a seizure but another question is more important.

Alanna tells the nurse the medication just made her feel funny and she really didn't think she would have any more seizures, so she quit taking it two weeks ago. Alanna is admitted into the hospital for observation.

Nursing Care

Alanna is admitted to the medical unit and her parents arrive a few minutes later. She is drowsy but arouses easily to verbal stimuli.

23.

Which intervention should the nurse implement?

A)Ask if she wants her parents in the room.

INCORRECTIn the Jewish tradition, the parents are typically respected and very active in their children's lives even into adulthood. While Alanna is drowsy, she does arouse easily and can ask her parents to leave if she doesn't want them in the room.

B)Pad and elevate the side rails of Alanna's bed.

CORRECTAlanna is at high risk for injury because of her recent seizure activity. Protecting her from injury by elevating and padding the side rails helps address Alanna's safety needs.

C)Place a padded tongue blade at the bedside.

INCORRECTThe nurse could place an oral airway at the bedside but once a seizure starts nothing should be placed in the client's mouth. A padded tongue blade should never be used since the client could bite down on the tongue blade and it could occlude the airway.

D)Attach a seizure precautions sign to the door.

INCORRECTDue to confidentiality issues, placing signs on a client's door is not encouraged except when it impacts the safety of healthcare providers, such as for needed isolation precautions.

Alanna's mother tells the nurse that neither she nor her father have ever seen Alanna have a seizure. They have read all the information on epilepsy and have talked to Alanna and the neurologist about the seizures but are very worried about their daughter. The mother tells the nurse, "I don't think I would know what to do if I saw her have a seizure."

24.

How should the nurse respond?

A)"The most important thing is to keep her from injuring herself."

CORRECTNothing can stop the seizure once it starts. Protecting the client from injury is the most important action to take.

B)"I know you would do the best that you could for your daughter."

INCORRECTThis statement does not help empower Alanna's parents. The nurse should help the family learn how to care for Alanna during the seizure.

C)"It helps if you restrain her arms so that she won't flail about."

INCORRECTRestraining the client can cause injury to both the person having the seizure and the person trying to restrain the seizing client.

D)"You should make sure she takes her medication every day."

INCORRECTAlanna is 23-years-old and must take responsibility for the management of her disease process.

Cultural Issues

Alanna's primary nurse realizes that Alanna is of the Jewish faith and wants to provide culturally sensitive nursing care during her hospitalization.

25.

Which statement reflects that the nurse is sensitive to Alanna's cultural needs?

A)"No one will interrupt you during Friday morning prayers."

INCORRECTThe Jewish holy day lasts from Friday night to Saturday night.

B)"The hospital chaplain will come visit you every day."

INCORRECTRabbis assist Jewish people with their spiritual needs. A hospital chaplain, typically of the Christian faith, can contact a rabbi at Alanna's request, but offering a daily visit by the hospital chaplain does not indicate the nurse understands the Jewish faith.

C)"Tell me about the type of Jewish teachings you practice."

CORRECTMany people of the Jewish faith practice different teachings, some more Orthodox and some more liberal. Therefore the nurse needs to know about Alanna's practices to help meet her cultural needs.

D)"You can be moved to a room with another Jewish person."

INCORRECTRoom assignments are based primarily on clients' medical diagnoses rather than a shared culture.

Alanna later tells the nurse that she and her family do follow a kosher diet. The next morning, Alanna's parents arrive at the nurses' station with a kosher breakfast for Alanna, which includes a bagel, scrambled eggs, and a glass of orange juice. Alanna has no prescribed dietary restrictions.

26.

What action should the nurse take?

A)Inform Alanna's parents that it would be better if they allowed their daughter to eat the food cooked by the hospital.

INCORRECTSince Alanna's diet is not restricted, there is no reason she cannot eat foods brought by her family.

B)Exchange the food provided on the hospital tray with the kosher food and deliver the tray to Alanna's room.

INCORRECTFoods prepared following kosher rules should not be served on dinnerware used for non-kosher foods.

C)Return the tray provided by the hospital and ask the parents if they would like to take the meal they provided to Alanna's room.

CORRECTThis action supports Alanna's cultural food preferences and also ensures that the kosher foods do not come in contact with non-kosher foods, and are not inadvertently served on dinnerware used for non-kosher foods.

D)Offer to order additional guest trays from the hospital kitchen so that Alanna's parents can eat with her.

INCORRECTSince the parents brought kosher food to the hospital, it is likely they are concerned that the hospital does not follow kosher rules for food preparation.

Discharge Home

Alanna is discharged from the hospital after 2 days. Her Dilantin level is 10.4 mcg/ml after receiving intravenous Dilantin. Alanna's neurologist is changing Alanna's anticonvulsant from Dilantin to valproic acid (Depakote) to reduce possible side effects and increase her compliance with medication administration.

27.

Which action should the nurse include when providing discharge teaching regarding the new medication?

A)Explain to the client that many clients get a rash that will go away with time.

INCORRECTA skin rash is an adverse reaction and should be reported to the healthcare provider.

B)Advise the client that, unlike Dilantin, drug levels will not need to be checked.

INCORRECTThe therapeutic level of Depakote is 50 to 100 mcg/ml which is monitored at least monthly initially and then every 6 months.

C)Instruct the client to take this medication on an empty stomach to help with absorption.

INCORRECTThis medication can be taken with food to help decrease gastric irritation.

D)Discuss with the client the importance of having liver function tests while on this medication.

CORRECTThis medication is heptotoxic so liver function tests are monitored at follow-up visits.

Prior to Alanna's discharge the nurse evaluates the client teaching provided during this hospitalization.

28.

When planning care, which client teaching goal is most important when determining Alanna's understanding? The client will

A)Agree to attend support group meetings regularly.

INCORRECTAttendance at support groups is highly recommended but this is not the most important goal for the nurse to evaluate during discharge teaching.

B)Have no seizure activity for the next 6 months.

INCORRECTThis long-term goal evaluates the client's compliance with the plan of care, but cannot be evaluated at the time of discharge.

C)Describe five strategies to prevent seizure activity.

CORRECTA correct description of the needed information is the best way to evaluate if teaching was effective. Remember goals must be measurable. Stating the correct dosage, side effects, when to call the healthcare provider, and the importance of follow-up visits are appropriate goals when evaluating the effectiveness of client teaching.

D)Demonstrate how to correctly take her medication.

INCORRECTPutting a tablet/capsule in the mouth does not evaluate Alanna's understanding of the discharge teaching.

Case Outcome

Alanna continues to work as a sales clerk, plans to graduate from college next semester and remains active in the Shalom Synagogue. She, her roommate, and her parents attend the monthly Epilepsy Support Group at the local hospital. The new anticonvulsant, Depakote, does not make her feel funny and she takes it faithfully. With her positive attitude toward life, her strong Jewish faith, and the support of her family and friends she intends to live a very full and productive life. And, by the way, she met a very nice young Jewish man, told him about her epilepsy, and they are now engaged to be married.