What is the nursing action of highest priority to be taken with a patient who experiences a generalized tonic clonic seizure?

ANS: C

In a generalized, or grand mal, seizure the patient may experience incontinence along with jerking, or tonic-clonic, movements of the entire body. An aura is an individualized, subjective auditory, visual, olfactory, or taste hallucination that may precede a seizure. Postictal is the period of recovery after a seizure; it may be characterized by confusion and sedation. A simple partial seizure may be isolated to one side of the brain and remain partial or focal in nature, or it may spread to involve the entire brain, culminating in a generalized tonic-clonic seizure. Simple partial seizures generally do not involve loss of consciousness and rarely last more than one minute.

ANS: B

Diplopia is a sign of phenytoin toxicity. The nurse should assess for other signs of toxicity, which include neurologic changes, such as nystagmus, ataxia, confusion, dizziness, or slurred speech. An aura, focal seizure, abdominal pain or cramping, irregular pulse, and palpitations are not associated with phenytoin toxicity.

The nurse is reviewing the clinical data of four patients with seizure disorders. Which patient would be most suitable for surgery?

Patient A: loss of consciousness, ineffective drug therapy, increased blood pH, Abnormal EEG

Patient B: Altered consciousness, effective drug therapy, decreased blood pH, Normal EEG

Patient C: Alert, effective drug therapy, normal blood pH, Normal EEG

Patient D: Confused, ineffective drug therapy, normal blood pH, normal EEG

What is the priority intervention for a patient experiencing a tonic

What is the nurse's most important intervention for a client having a tonic

Which priority intervention would the nurse implement when a patient experiences a seizure lasting more than 5 minutes?

What are some nursing care priorities for a patient with seizures?