Question

The nurse is caring for a 3-year-old child with a history of seizures and observes the child having a seizure. Following the seizure activity, what information does the nurse document? Select all that apply.

A) Time the seizure started
B) Factors present before seizure started
C) Eye position and movement
D) Incontinence of urine or stool

Answer 1

The nurse should document the time the seizure started, factors present before the seizure, eye position and movement, and incontinence of urine or stool.

Step-by-step explanation:

The nurse should document the following information:

• Time the seizure started: Documenting the time the seizure started is important for evaluating the duration of the seizure and determining appropriate interventions.
• Factors present before the seizure started: Documenting any factors present before the seizure, such as stress, sleep deprivation, or medication changes, can help identify potential triggers for future seizures.
• Eye position and movement: Documenting the eye position and movement during the seizure can provide valuable information about the type of seizure and potential areas of brain involvement.
• Incontinence of urine or stool: Documenting incontinence of urine or stool can indicate the severity of the seizure activity and potential impact on the child's overall health.