The nurse is assessing a patient recovering from a tonic-clonic seizure. Which finding indicates a need for immediate nursing intervention?
a. The patient is difficult to arouse.
b. The patient has been incontinent of urine.
c. The patient has frothy sputum in the pharynx and gurgling respirations.
d. The patient becomes belligerent when the nurse does neurological assessments.
ANS: C
Gurgling respirations and frothy sputum indicate aspiration, and a clear airway is a priority. A. B. Difficulty arousing and incontinence of urine are not uncommon findings after a tonic-clonic seizure. D. Belligerence is a concern but is not life threatening.
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