Neurological Question #23

Question

During the ictal phase, which of the following is important in the assessment of the client?

Answers

  1. Vital signs including oximeter readings.
    • Rationale:
  2. Movement of eyes, head, and muscle rigidity.
    • Rationale:
  3. Determining what type of aura occurred.
    • Rationale:
  4. Determining what the client was doing just prior to the seizure.
    • Rationale:

Overview

Explanation

Assessment of eye movement, head movement, and rigidity is important to document along with timing and type and duration of movements which may provide indication of where the foci in the brain are located. Other assessment during seizure includes respiration/airway, duration of seizure, loss of consciousness, incontinence, and full neuro assessment. During the ictal phase (which is during the seizure) vital signs may not be obtainable due to muscular rigidity and movement. Since the client may not be awake, the nurse may not determine type of auras or triggers/activity prior to the seizure.

Learning Outcomes

Test Taking Tip

Video Rationale