What will the nurse include then documenting a grand mal seizure? (Select all that apply.)
a. Presence of incontinence
b. Current dose of antispasmodic medication
c. Activity level prior to and following seizure
d. Level of consciousness following seizure
e. Length of seizure
ANS: A, C, D, E
Documentation on a seizure should include LOC following episode, activity prior to and following seizure, change in color, respiration, muscle tone, and length of seizure. Reporting of medication regimen is not necessary.
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