Neurological Question #22

Question

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

Answers

  1. Assess level of lethargy and sleepiness.
    • Rationale:
  2. Place pillow under the head.
    • Rationale:
  3. Reorient the client to surroundings and environment.
    • Rationale:
  4. Perform a respiratory assessment.
    • Rationale:

Overview

Explanation

During the postictal phase, the nurse should monitor respiratory patterns and assess oxygen and ventilation since airway is important. Assessing for sleepiness is not a priority since it may be a common symptom after a seizure. Ensuring comfort is important but not a priority. Reorientation is important but airway clearance is of most priority since the client may have aspirated during the ictal or middle stage when loss of awareness and inability to swallow may occur.

Learning Outcomes

Test Taking Tip

Video Rationale