The nurse is caring for a patient following surgery for a brain tumor. Three days after surgery, the LVN enters the room and finds the patient jerking rhythmically in the bed. The patient does not respond to the LVN's questions. What should the nurse do first?

Question

Quizplus · Accepted Answer

The patient may be experiencing a seizure, which is a potential complication after brain surgery. The priority is to protect the patient from injury by removing any sharp objects from the bed and placing pillows around them. The nurse should also observe and document the sequence of events, including the time the seizure started and any characteristics of the seizure, such as the duration and type of movements. After protecting the patient, the nurse should notify the RN and physician as soon as possible. While holding the patient may be necessary to prevent injury, it is not the first action the nurse should take.

The Nurse Is Caring for a Patient Following Surgery for a Brain