A child presents to the unit with a history of petit mal seizures. After one such episode, the nurse correctly documents that "The client:
1. "Became unconscious, and all four extremities were jerking uncontrollably for two minutes.".
2. "Was sitting very still and stared off into space for a period of two minutes.".
3. "Repeatedly moved from the chair to the bed while touching her arms for a length of two minutes.".
4. "Pulled her arms in toward her body and flexed her hands over her chest. This lasted two minutes.".
2. "Was sitting very still and stared off into space for a period of two minutes.".
Rationale:
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 that 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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