The nurse observes a school-age client have an absence seizure. When documenting the seizure in the medical record, which is the most appropriate?
A) "Pulled arms in toward the body and flexed hands over the chest. This lasted 2 minutes."
B) "Became unconscious, and all four extremities were jerking uncontrollably for 2 minutes."
C) "Repeatedly moved from the chair to the bed while touching the arms for a length of 2 minutes."
D) "Sat very still and was unresponsive with a blank stare for 2 minutes."
Answer: D
Absence (petit mal) seizures are characterized by sudden, brief cessation of all motor activity accompanied by a blank stare and unresponsiveness. These seizures are more common in children than in adults. Jerking of extremities and periods of nonpurposeful movements describe grand mal and generalized seizure activity. Decerebrate posturing is a sign of increased ICP.
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