The nurse observes a patient ambulating in the hospital hall when the patient's arms and legs suddenly jerk and the patient falls to the floor. The nurse will first
a. assess the patient for a possible head injury.
b. give the scheduled dose of divalproex (Depakote).
c. document the timing and description of the seizure.
d. notify the patient's health care provider about the seizure.
ANS: A
The patient who has had a myoclonic seizure and fall is at risk for head injury and should first be evaluated and treated for this possible complication. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications are also appropriate actions, but the initial action should be assessment for injury.
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