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