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