Page 2019 - Saunders Comprehensive Review For NCLEX-RN

4. Tinnitus
5. Hemiparesis
6. Nuchal rigidity
7. Seizures

C. Interventions

1. Maintain a patent airway (suction only with an
PHCP’s prescription).
2. Administer oxygen as prescribed.
3. Monitor vital signs and for hypertension or
dysrhythmias.
4. Avoid taking temperatures via the rectum.
5. Initiate aneurysm precautions (Box 58-12).
IX. Seizures
A. Description
1. Seizures are an abnormal, sudden, excessive discharge
of electrical activity within the brain.
2. Epilepsy is a disorder characterized by chronic seizure
activity and indicates brain or CNS irritation.
3. Causes include genetic factors, trauma, tumors,
circulatory or metabolic disorders, toxicity, and
infections.
4. Status epilepticus involves a rapid succession of
epileptic spasms without intervals of consciousness; it
is a potential complication that can occur with any
type of seizure, and brain damage may result.
B. Types of seizures (Box 58-13)

C. Assessment

1. Seizure history
2. Type of seizure
3. Occurrences before, during, and after the seizure
4. Prodromal signs, such as mood changes, irritability,
and insomnia
5. Aura: Sensation that warns the client of the impending
seizure
6. Loss of motor activity or bowel and bladder function
or loss of consciousness during the seizure
7. Occurrences during the postictal state, such as
headache, loss of consciousness, sleepiness, and
impaired speech or thinking

D. Interventions

If the client is having a seizure, maintain a patent airway. Do not force the jaws

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