Mr. K, age 21, is sitting in the emergency room (ER) waiting to be seen for an extended bout of the flu
that hasn't improved in 2 weeks. You are the triage nurse that evening when someone screams for help.
Mr. K. is having a tonic-clonic seizure. A medical alert bracelet indicates that he has epilepsy.
1) A tonic-clonic seizure is a partial seizure, localized to one area of the brain, with some
memory impairment.
a. True
b. False
False
Feedback: A tonic-clonic seizure is a generalized seizure that involves widespread areas of both
cerebral hemispheres.
2) What would you do at this time?
a. Place a tongue blade in his mouth.
b. Send him for a computed tomography (CT) scan at once.
c. Position him safely so that he maintains a patent airway.
d. Administer Valium 5 mg intravenously stat.
Correct Feedback:
C. This is a priority intervention. During a seizure, it is important to maintain a patent airway.
This might involve protecting the head, turning the client to the side, loosening constrictive
clothing, or easing the client to the floor if seated.
Incorrect Feedback:
A. No objects should be placed into the mouth of someone who is experiencing a seizure.
B. A CT scan is not indicated at this time. It might be done in any new-onset seizure to rule out a
structural lesion.
D. This might be indicated for status epilepticus, but this is not the situation now.
3) A factor that might have influenced Mr. K.'s threshold for a seizure is ________.
Answer: illness
Feedback: Illness lowers the threshold for a seizure. In addition, overall physical status and
other medications could influence seizure threshold.
4) Mr. K's seizure continues without regaining consciousness. This might represent ________
____________.
Answer: status epilepticus
Feedback: Status epilepticus is an emergency situation in which seizures recur in rapid succession and
the client does not regain consciousness. It lasts at least 30 minutes and is a life-threatening situation.
5) The major cause of status epilepticus is ________________________________.
Answer: noncompliance with medications
Feedback: Not taking prescribed medications can result in more frequent seizure occurrence and status
epilepticus. Status epilepticus can also be caused by central nervous system disorders, low blood sugar
level, or low blood calcium level.
6) Status epilepticus is a life-threatening situation because permanent brain damage might
result.
a. True
b. False
Answer: True
Feedback: Neurons become exhausted and cease to function. In addition ventilatory failure,
hypoxia, dysrhythmias, and acidosis can occur. All of these situations can be fatal.
7) A drug of choice in this situation is__________________________.
a.
b.
c.
d.
carbamazepine (Tegretol)
divalproex (Depakote)
primidone (Mysoline)
diazepam (Valium)
Correct Feedback:
D. Diazepam is a fast-acting benzodiazepine given intravenously for the termination of status
epilepticus.
Incorrect Feedback:
A. This is an anticonvulsant drug given orally for a generalized tonic-clonic seizure, but it is not
indicated in this emergency situation.
B. This is an anticonvulsant drug given orally for a generalized tonic-clonic seizure, but it is not
indicated in this emergency situation.
C. This is an anticonvulsant drug given orally for a generalized tonic-clonic seizure, but it is not
indicated in this emergency situation.
8) When administering an intravenous benzodiazepine such as Valium, the nurse
carefully monitors ___________________.
Answer: vital signs
Feedback: Baseline vital signs need to be obtained prior to dosing with Valium. Respirations
should be assessed before doses, and the client should be assessed for respiratory depression
and hypotension during administration and for at least 3 hours afterward. Emergency
equipment must be readily available.
9) Mr. K's seizure is controlled and he is transferred to a medical unit. The physician
plans a loading dose of fosphenytoin sodium (Cerebyx) 750 mg PE IV Soluset.
Fosphenytoin is ordered instead of phenytoin (Dilantin) because it is more effective in
controlling seizures.
a. True
b. False
Answer: False
Feedback: Fosphenytoin rapidly converts to phenytoin in the body. It has the same
pharmacologic profile as phenytoin sodium. 750 mg fosphenytoin sodium is equivalent to 500
mg phenytoin sodium. Phenytoin also is irritating to tissue and veins and is incompatible with
many solutions, making fosphenytoin a better choice.
10) The maximum rate of intravenous administration of fosphenytoin is ________.
Answer: 150 mg/min
Feedback: Fosphenytoin 150 mg is equivalent to 100 mg phenytoin sodium. The IV infusion rate
should not exceed 150 mg PE/min as a loading dose. The maintenance dose is 4 to 6 mg
PE/kg/day IV.
11) In assessing Mr. K., you discover that he has been noncompliant with his
prophylactic seizure medications at home. A factor that you consider when planning
your interventions to address his noncompliance is ________.
Answer: knowledge
Feedback: When examining noncompliance, the nurse should consider knowledge of his drug
regimen and take into consideration his age and developmental tasks, his financial status, his
self-image and goals, and his use of other substances such as alcohol.
12) Mr. K. will be discharged on phenytoin sodium (Dilantin). The nurse teaches him
oral hygiene, including brushing his teeth frequently, flossing, and massaging his
gums. This helps prevent ____________ ________________.
Answer: gingival hyperplasia
Feedback: Tissue overgrowth is usually more obvious anteriorly than posteriorly, and the client
might have body image concerns. Regular dental care together with measures to control plaque
will minimize hyperplasia.
13) The range for therapeutic phenytoin level is ________ mcg/mL.
Answer: 10 to 20
Feedback: Monitoring for a therapeutic level of 10 to 20 mcg/mL is important for accurate
dosage administration and as a mechanism of determining compliance.
14) Mr. K. asks about a resource to help him learn more about his epilepsy. A
voluntary agency that offers a variety of services to individuals with epilepsy at no
cost is the _______________________.
Answer: Epilepsy Foundation
Feedback: Support from others with epilepsy as well as information on current care and
management will empower Mr. K. and foster compliance.