The health care provider is considering the use of sumatriptan (Imitrex) for a 54-year-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?

A. Monitor level of consciousness (LOC): While monitoring the patient's level of consciousness is important, administering medication to stop the seizure takes precedence to prevent potential complications associated with prolonged seizure activity.

B. Administer lorazepam (Ativan) 4 mg IV: The priority in managing continuous tonic-clonic seizures is to terminate the seizure activity promptly. Lorazepam is a benzodiazepine that can help to abort seizures and is often used as first-line treatment in the acute setting.

C. Obtain computed tomography (CT) scan: While obtaining diagnostic imaging such as a CT scan may be necessary to evaluate for underlying causes of the seizure, it is not the first
intervention in the acute management of continuous seizures. Stabilizing the patient and stopping the seizure activity take precedence.

D. Give phenytoin (Dilantin) 100 mg IV: Phenytoin is an antiepileptic medication that is used for long-term management of seizures but is not typically administered as first-line treatment during an acute seizure episode. Benzodiazepines like lorazepam are preferred for immediate seizure control.

The potential condition the client is most likely experiencing is a Hemorrhagic Stroke.

1. Prepare the client for a STAT CT brain: The client presents with sudden onset of severe headache described as the worst of their life, along with additional neurological symptoms such as left-sided weakness, aphasia, photophobia, and loss of peripheral vision. These symptoms are highly concerning for a possible hemorrhagic stroke, which requires urgent imaging such as a CT scan of the brain to confirm the diagnosis and guide immediate treatment.
2. Place the client on seizure precautions: The client has reported left-sided weakness and aphasia, indicating neurological deficits. Additionally, they have a history of atrialfibrillation and are on anticoagulant therapy with warfarin, resulting in an elevated INR of4.9. This INR level suggests a significantly increased risk of bleeding, including intracranial bleeding. Given these factors, the client is at risk of experiencing seizures, which is a potential complication of hemorrhagic stroke. Placing the client on seizure precautionsinvolves ensuring their safety and preventing injury in the event of a seizure.

Parameters to Monitor:

1. Temperature: Monitoring temperature is important to assess for the presence of fever, which could indicate an infectious process such as meningitis. However, in this case, theclient's fever is likely related to their urinary tract infection rather than directly related to the stroke. Nonetheless, monitoring temperature is still essential for overall assessment and management.
2. PT/INR: Monitoring the PT/INR is crucial due to the client's history of atrial fibrillation and anticoagulant therapy with warfarin. The elevated INR of 4.9 suggests that the client is at increased risk of bleeding, including intracranial bleeding. Close monitoring of PT/INR levels will help guide adjustments to anticoagulant therapy and assess the risk of further bleeding complications.