Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?
A) Seizure began at 1300 hours.
B) The client cried out before the seizure began.
C) Seizure was 1 minute in duration including tonic-clonic activity.
D) Sleeping quietly after the seizure
C
Feedback:
Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and their skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.
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