Medical Surgical Seizures #10

Question

The nurse assesses a client in the postictal phase (recovery phase). Which of these actions will the nurse prioritize during the postictal phase of a seizure?

Answers

  1. Assess level of lethargy and sleepiness.
    • Rationale:

      This answer is not correct because assessing for sleepiness is not a priority since it may be a common symptom after a seizure. Drowsiness is part of the postictal phase of a seizure and the body will need time to rest. A respiratory assessment is priority during the postictal phase of a seizure.

  2. Place a pillow under the head.
    • Rationale:

      This answer is not correct because ensuring comfort is important but not a priority. It is also likely the client will not be aware of their comfort during this postictal phase due to confusion or drowsiness.

  3. Reorient the client to surroundings and environment.
    • Rationale:

      This answer is not correct because reorientation is important but airway clearance is of most priority. The client may have aspirated during the ictal or middle stage when loss of awareness and inability to swallow may occur. A respiratory assessment is priority during the postictal phase of a seizure.

  4. Perform a respiratory assessment.
    • Rationale:

      This answer is correct because during the ictal phase of the seizure, there is possibility of aspiration. The nurse should monitor respiratory patterns and assess oxygen and ventilation while the client is in the postictal state. Assessing respiratory status during this state is the nursing action of priority.

Overview

The postictal phase of a seizure is the recovery period after the seizure ends. During this phase the nurse should perform a respiratory assessment.

Explanation

Learning Outcomes

The length of the postictal phase (recovery phase) of a seziure is dependent on the type of seizure. It can last anywhere from minutes to days. During this phase, the client may feel sore, confused, sleepy, weak, and even experience feelings of sadness. During the postictal state, it is important to keep the client safe from injury until this phase resolves. Often before this state, the client may have respiratory depression or may have aspirated. Respiratory assessment will be necessary following a seizure.

Test Taking Tip

Knowing four phases of a seizure and symptoms during each will help students answer this question. Remember to always prioritize airway and breathing and this will guide your way!

Video Rationale