A nurse is caring for a client who has epilepsy and is experiencing status epilepticus. Which of the following actions should the nurse take first?

Choice A reason:

This is a correct answer. The nurse should advise the client and their caregiver to avoid triggers such as stress, fatigue, or flashing lights that may provoke seizure activity by altering brain electrical activity or neurotransmitter levels. The nurse should also educate them about other potential triggers such as alcohol, caffeine, nicotine, fever, infection, hormonal changes, or certain medications.

Choice B reason:

This is a correct answer. The nurse should advise the client and their caregiver to follow a ketogenic diet that is high in fat and low in carbohydrates under medical supervision if pharmacological therapy is ineffective or intolerable. A ketogenic diet can reduce seizure frequency and severity by inducing ketosis, which is a metabolic state where ketone bodies are used as an alternative fuel source for the brain instead of glucose.

Choice C reason:

This is a correct answer. The nurse should advise the client and their caregiver to wear a medical alert bracelet or necklace that identifies epilepsy and provides emergency contact information. This can help ensure prompt and appropriate care in case of a seizure and prevent unnecessary interventions or complications.

Choice D reason:

This is an incorrect answer. The nurse should not advise the client and their caregiver to use herbal remedies such as valerian or chamomile to reduce anxiety, as this can have negative effects on seizure activity and medication effectiveness. Herbal remedies can interact with antiepileptic drugs (AEDs) and alter their absorption, metabolism, or excretion, which can increase the risk of toxicity or breakthrough seizures. The nurse should advise the client and their caregiver to consult their provider before using any herbal remedies or supplements.

Choice E reason:

This is a correct answer. The nurse should advise the client and their caregiver to perform relaxation techniques such as deep breathing or meditation, as this can help prevent seizures by reducing stress, anxiety, or tension that may trigger seizure activity. Relaxation techniques can also improve mood, sleep quality, and coping skills for the client and their caregiver.

Choice A reason:

This is an incorrect answer. Administering IV lorazepam as prescribed is an important action for the nurse to take for a client who has epilepsy and is experiencing status epilepticus, but it is not the first action. Lorazepam is a benzodiazepine that can stop or reduce seizure activity by enhancing the inhibitory effects of gamma-aminobutyric acid (GABA) in the brain. However, before administering any medication, the nurse should ensure that the client's airway and head are protected from injury or obstruction.

Choice B reason:

This is a correct answer. Protecting the client's airway and head is the first action that the nurse should take for a client who has epilepsy and is experiencing status epilepticus. Status epilepticus is a medical emergency that occurs when a seizure lasts longer than 5 minutes or when two or more seizures occur without recovery of consciousness in between. Status epilepticus can cause hypoxia, brain damage, or death if not treated promptly. The nurse should protect the client's airway and head by placing them in a side-lying position, removing any objects or clothing that may restrict breathing, inserting an oral airway if needed, and padding the side rails or bed to prevent injury.

Choice C reason:

This is an incorrect answer. Monitoring the client's vital signs and oxygen saturation is an important action for the nurse to take for a client who has epilepsy and is experiencing status epilepticus, but it is not the first action. Vital signs and oxygen saturation can indicate the severity and effects of seizure activity on the client's cardiovascular, respiratory, and neurological systems. The nurse should monitor these parameters closely and provide oxygen therapy if needed to maintain adequate oxygenation and perfusion of the brain. However, before monitoring any parameters, the nurse should ensure that the client's airway and head are protected from injury or obstruction.

Choice D reason:

This is an incorrect answer. Documenting the onset, duration, and characteristics of the seizure is an important action for the nurse to take for a client who has epilepsy and is experiencing status epilepticus, but it is not the first action. Documentation can provide valuable information for diagnosis, treatment, and evaluation of seizure activity and its effects on the client's condition and quality of life. The nurse should document these details accurately and objectively as soon as possible after the seizure ends. However, before documenting any details, the nurse should ensure that the client's airway and head are protected from injury or obstruction.