An emergency department (ED) client's wife says, "I couldn't wake my husband up this morning. He was snoring so loudly. Why, he was so asleep he urinated in the bed. He has never done anything like this before and he is okay now."
Which question is the priority for the nurse to ask the client's wife?
1. "Does your husband have diabetes?"
2. "Was your husband especially active yesterday?"
3. "Has your husband ever had a seizure?"
4. "What kind of street drugs did your husband take last night?"
Correct Answer: 3
Rationale 1: While high blood glucose levels might result in a comatose state, it would be unlikely for the client to be "okay" without intervention.
Rationale 2: The occurrences described by this client's wife are unlikely to be a result of simple exhaustion.
Rationale 3: Being difficult to awaken and sonorous respirations are findings associated with the postictal state common after seizure activity. Persons experiencing seizures may be incontinent of urine or stool. When the postictal state passes, the client may appear normal or "okay."
Rationale 4: Confronting the wife with an accusation that her husband uses illegal drugs may shut down the communication necessary to determine the etiology of the client's illness.
Global Rationale: Being difficult to awaken and sonorous respirations are findings associated with the postictal state common after seizure activity. Persons experiencing seizures may be incontinent of urine or stool. When the postictal state passes, the client may appear normal or "okay." While high blood glucose levels might result in a comatose state, it would be unlikely for the client to be "okay" without intervention. The occurrences described by this client's wife are unlikely to be a result of simple exhaustion. Confronting the wife with an accusation that her husband uses illegal drugs may shut down the communication necessary to determine the etiology of the client's illness.
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