A client who is on seizure precautions experiences a seizure while ambulating in the room. What should the nurse include in this client's documentation?
1. Who assisted the client back to bed.
2. Location of the seizure.
3. Duration of the seizure.
4. Status of airway and use of oxygen.
5. Who discovered the client.
Correct Answer: 2,3,4
Rationale 1: It is not important for the nurse to name the individuals who assisted the client back to bed.
Rationale 2: Documentation should include where the client was when the seizure occurred.
Rationale 3: Documentation should include the duration of the seizure.
Rationale 4: Documentation should include the status of the client's airway and use of oxygen.
Rationale 5: It is not important for the nurse to name the individual who found the client having a seizure.
You might also like to view...
The nurse assesses a patient for tactile fremitus. Which statement best defines tactile fremitus?
1) Palpable vibrations 2) Audible voice sounds 3) Audible breath sounds 4) Palpable chest movement
The nurse explains to the patient that the obstetric conjugate measurement is important because:
1. This measurement determines the tilt of the pelvis. 2. This measurement determines the shape of the inlet. 3. The fetus passes under it during birth. 4. The size of this diameter determines whether the fetus can move down into the birth canal so that engagement can occur.
The nurse is examining a female with vaginal discharge. Which position will the nurse place the patient for proper examination?
a. Sitting b. Lithotomy c. Knee-chest d. Dorsal recumbent
What initiates inflammation in acute poststreptococcal glomerulonephritis?
a. Lysosomal enzymes b. Endotoxins from Streptococcus c. Immune complexes d. Immunoglobulin E (IgE)–mediated response