Question

The nurse is preparing to assess a client that had a​ tonic-clonic seizure. Which assessment findings should the nurse​ anticipate? select all that apply.

a. Incontinence of urine.
b. The client is in a deep sleep.
c. Confusion in relation to place and time.
d. The client reports of an odd taste in the mouth.
e. The client attempting to remove their hospital gown.

Answer 1

A nurse should anticipate that a client who had a tonic-clonic seizure may experience incontinence of urine, be in a deep sleep postictally, and have confusion regarding place and time. It is less likely for a patient to attempt to remove their hospital gown or report an odd taste in the mouth, as these are not typical postictal symptoms.

Step-by-step explanation:

When assessing a client following a tonic-clonic seizure, a nurse should anticipate a few specific findings due to the nature of the seizure. These include:

• Incontinence of urine: During a seizure, control over bladder function may be lost, leading to incontinence.
• The client is in a deep sleep (postictal state): After seizures, patients often enter a state of deep rest or sleep as their body recuperates.
• Confusion about place and time: Postictal confusion is common as the brain recovers from the seizure activity.

Clients may not necessarily attempt to remove their hospital gown as this behavior is not typically associated with the postictal state; similarly, an odd taste in the mouth is more likely to be a symptom that precedes a seizure (an aura) rather than a postictal symptom. Therefore, options a, b, and c are the anticipated findings the nurse should prepare to encounter.