Page 2020 - Saunders Comprehensive Review For NCLEX-RN

open or place anything in the client’s mouth.
1. Note the time and duration of the seizure.
2. Assess behavior at the onset of the seizure: If the client
has experienced an aura, if a change in facial
expression occurred, or if a sound or cry occurred
from the client.
3. If the client is standing or sitting, place the client on
the floor and protect the head and body.
4. Support airway, breathing, and circulation.
5. Administer oxygen.
6. Prepare to suction secretions.
7. Turn the client to the side to allow secretions to drain
while maintaining the airway.
8. Prevent injury during the seizure.
9. Remain with the client.
10. Do not restrain the client.
11. Loosen restrictive clothing.
12. Note the type, character, and progression of the
movements during the seizure.
13. Monitor for incontinence.
14. Administer intravenous medications as prescribed to
stop the seizure.
15. Document the characteristics of the seizure.
16. Provide privacy.
17. Monitor behavior following the seizure, such as the
state of consciousness, motor ability, and speech
ability.
18. Instruct the client about the importance of lifelong
medication and the need for follow-up determination
of medication blood levels.
19. Instruct the client to avoid alcohol, excessive stress,
fatigue, and strobe lights.
20. Encourage the client to contact available community
resources, such as the Epilepsy Foundation of
America.
21. Encourage the client to wear a MedicAlert bracelet.

X. Stroke (Brain Attack)

A. Description
1. A stroke or brain attack manifests as a sudden focal
neurological deficit and is caused by cerebrovascular
disease.
2. Cerebral anoxia lasting longer than 10 minutes causes
cerebral infarction with irreversible change.
3. Cerebral edema and congestion cause further
dysfunction.
4. Diagnosis is determined by a CT scan,
electroencephalography, cerebral arteriography, and

2020