Difficulty: Medium
Average Score: 79%
Simulated
A client is brought to the emergency department (ED) by a friend who states that the client recently ran out of his phenytoin (Dilantin) and has been having a grand mal seizure for the last 10 minutes. The nurse observes that the client is still seizing. The nurse should do the following in which order of priority from first to last?
Correct answer
A, C, B, D
Rationale
The order is: 1) Monitor safety with seizure pads (A). 2) Page physician and prepare diazepam (C). 3) Record seizure details (B). 4) Ask about medical history (D). Safety and treatment are prioritized, followed by documentation and history.