, 1. A nurse is assessing a patient who has a history of seizures. The nurse
observes that the patient has brief, jerky movements of the arms and legs
that occur every few seconds. The nurse should document this as:
a) Myoclonic seizures
b) Tonic-clonic seizures
c) Absence seizures
d) Atonic seizures
*Answer: a) Myoclonic seizures*
Rationale: Myoclonic seizures are characterized by sudden, brief
contractions of a muscle or group of muscles. They may occur in clusters
or singly and may or may not be symmetric. Tonic-clonic seizures involve
a loss of consciousness, stiffening of the body, and rhythmic jerking of the
limbs. Absence seizures are brief episodes of staring, often with subtle eye
blinking or lip smacking. Atonic seizures are sudden losses of muscle
tone, causing the person to fall or drop the head.
2. A nurse is caring for a patient who has a Glasgow Coma Scale (GCS)
score of 8. The nurse should interpret this as:
a) Mild brain injury
b) Moderate brain injury
c) Severe brain injury
d) Normal brain function
*Answer: c) Severe brain injury*
Rationale: The GCS is a tool used to assess the level of consciousness and
neurological function of a patient. It consists of three components: eye
opening, verbal response, and motor response. The scores range from 3 to
15, with lower scores indicating more severe impairment. A GCS score of
8 or less indicates a severe brain injury, while a score of 9 to 12 indicates
a moderate brain injury, and a score of 13 to 15 indicates a mild brain
injury or normal brain function.
3. A nurse is performing a neurologic assessment on a patient who has a
suspected stroke. The nurse asks the patient to smile and observes that one
side of the face droops. The nurse should document this as:
a) Anosognosia
b) Hemianopia
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