The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the patient has a seizure
In preparation for documenting this clinical event, the nurse should note which of the following?
A) The ability of the patient to follow instructions during the seizure.
B) The success or failure of the care team to physically restrain the patient.
C) The patient's ability to explain his seizure during the postictal period.
D) The patient's activities immediately prior to the seizure.
Ans: D
Feedback:
Before and during a seizure, the nurse observes the circumstances before the seizure, including visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; and hyperventilation. Communication with the patient is not possible during a seizure and physical restraint is not attempted. The patient's ability to explain the seizure is not clinically relevant.
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