Seizure Case Study

A client with a history of probable seizures over the past 2 months is sitting in a neurologist’s waiting room when another client suddenly develops full-body rigidity, rhythmic arm and leg movements, and makes guttural sounds. What type of seizure is being observed?

Tonic-clonic (generalized) seizure

In the waiting room scenario where a client begins having a tonic-clonic seizure, what is the priority nursing action?

Protect the client from injury (ease to the floor if needed, remove nearby objects, do not restrain).

Why should the nurse NOT insert anything into the client’s mouth during an active seizure?

Because it increases the risk of airway obstruction, aspiration, and dental injury.

After initial safety interventions, the client continues to have a tonic-clonic seizure. What is the most important nursing action to perform next?

Note the time, duration, and characteristics of the seizure.

Why is documenting the time, duration, and type of seizure critical?

It guides diagnosis, treatment decisions, and determines whether the client is progressing toward status epilepticus.

After the seizure ends, the client is moved to a private room, is oriented but very lethargic, and has no apparent injuries. What phase is the client experiencing?

Postictal phase

Why is the client very lethargic during the postictal phase?

Due to temporary cerebral exhaustion after excessive neuronal firing during the seizure.

What nursing intervention is most appropriate during the postictal phase?

Turn the client to the side and allow rest, maintaining airway and safety.

Why should the nurse avoid excessive questioning during the postictal phase?

The client may be confused, fatigued, and temporarily unable to process information.

A neurologist prescribes phenytoin for seizure prevention. What key oral care instruction should the nurse emphasize?

Brush and floss teeth after every meal to prevent gingival hyperplasia.

Why is gingival hyperplasia a major teaching point for phenytoin?

Because phenytoin causes gum overgrowth and bleeding, which can be minimized with good oral hygiene.

Which client statement shows correct understanding of phenytoin teaching?

“I must brush and floss my teeth after every meal.”

Why is the statement “I will not have seizures since I’m on this medication” incorrect?

Anticonvulsants reduce seizure frequency, but do not guarantee complete prevention.

Which instruction should the nurse include regarding safety and daily activities while taking phenytoin?

Avoid hazardous tasks until the drug level is stabilized, due to dizziness and coordination changes.

Why should alcohol intake be limited while taking phenytoin?

Alcohol alters phenytoin metabolism and increases seizure risk.

Three weeks later, the same client arrives at the ED after having two seizures back-to-back at home. The client is lying on a stretcher with eyes closed and no active seizure. What is the priority nursing intervention?

Assess vital signs

Why is assessing vital signs the priority after seizure activity?

To evaluate airway, breathing, circulation, and identify complications such as hypoxia or hypotension.

The client’s serum phenytoin level is 7 mcg/mL (therapeutic range 10–20 mcg/mL). What does this indicate?

Subtherapeutic phenytoin level, increasing seizure risk.

The provider orders phenytoin 25 mg IV push. The client has D5W running. What action should the nurse take?

Dilute the medication and flush the tubing before and after with normal saline.

Why should phenytoin NOT be administered with D5W?

Phenytoin precipitates in dextrose solutions, reducing effectiveness and risking IV complications.

Why should phenytoin be administered slowly IV?

Rapid administration can cause hypotension and cardiac dysrhythmias.

After awakening, the client does not remember the seizure and recalls only hearing a buzzing sound beforehand. What does this suggest?

An aura, indicating focal onset before generalized seizure.

What is the most important follow-up question the nurse should ask to identify seizure cause?

“Have you been taking your medication regularly?”

Why is medication adherence the priority question?

Missed anticonvulsant doses are a common and preventable cause of breakthrough seizures.

A client in a neurologist’s waiting room suddenly becomes rigid, begins rhythmic jerking of the arms and legs, and makes guttural sounds. What is the nurse’s priority action?

A. Insert an oral airway
B. Restrain the client’s extremities
C. Protect the client from injury
D. Call the neurologist immediately

C
Rationale: During an active tonic-clonic seizure, the priority is safety. The nurse should protect the client from injury and not restrain or insert objects into the mouth.

A client continues to have a tonic-clonic seizure after safety measures are initiated. What action should the nurse perform next?

A. Check for urinary incontinence
B. Notify the healthcare provider
C. Insert an oral airway
D. Note the time, duration, and type of seizure

D
Rationale: Accurate documentation of seizure duration and characteristics is essential for diagnosis and treatment planning.

After seizure activity stops, the client is oriented but extremely lethargic. What phase of seizure activity is the client experiencing?

A. Aura
B. Ictal phase
C. Postictal phase
D. Status epilepticus

C
Rationale: The postictal phase is characterized by lethargy, confusion, and cerebral exhaustion following seizure activity.

Which nursing intervention is most appropriate during the postictal phase?

A. Perform a detailed neurological interview
B. Turn the client to the side and allow rest
C. Encourage oral fluids immediately
D. Ambulate the client to assess balance

B
Rationale: Side-lying positioning maintains airway patency and allows the brain to recover.

A client is prescribed phenytoin for seizure prevention. Which statement indicates correct understanding of medication teaching?

A. “I will never have seizures while on this medication.”
B. “I should brush and floss my teeth after every meal.”
C. “I can stop taking the medication once seizures stop.”
D. “I only need to take the medication when I feel a seizure coming.”

B
Rationale: Phenytoin can cause gingival hyperplasia; excellent oral hygiene is essential.

Which instruction should the nurse include for a client newly prescribed phenytoin?

A. Avoid all dairy products
B. Take the medication only at bedtime
C. Avoid hazardous activities until drug levels stabilize
D. Skip doses if feeling dizzy

C
Rationale: Phenytoin can cause dizziness and impaired coordination until therapeutic levels are achieved.

A client arrives in the emergency department after two seizures occurring back-to-back at home. The client is not actively seizing. What is the nurse’s priority intervention?

A. Obtain a serum phenytoin level
B. Apply a cardiac telemetry monitor
C. Ensure suction equipment is available
D. Assess vital signs

D
Rationale: Airway, breathing, and circulation must be assessed first following seizure activity.

A client’s serum phenytoin level is 7 mcg/mL (therapeutic range 10–20 mcg/mL). How should the nurse interpret this finding?

A. Toxic level
B. Therapeutic level
C. Subtherapeutic level
D. Expected during long-term therapy

C
Rationale: A level below 10 mcg/mL increases the risk for breakthrough seizures.

The nurse is preparing to administer IV phenytoin to a client receiving D5W. What action should the nurse take?

A. Administer phenytoin undiluted
B. Mix phenytoin with D5W
C. Flush the IV line with normal saline before and after administration
D. Administer phenytoin rapidly to prevent seizures

C
Rationale: Phenytoin precipitates in dextrose solutions and must be flushed with normal saline.

After awakening, a client reports hearing a buzzing sound just before losing consciousness during a seizure. How should the nurse interpret this information?

A. Postictal confusion
B. Status epilepticus
C. Febrile seizure
D. Aura

D
Rationale: An aura is a sensory warning that may precede a seizure.

Which question is most important for the nurse to ask a client with recurrent seizures?

A. “Were you under stress recently?”
B. “Are you currently menstruating?”
C. “Have you been taking your medication regularly?”
D. “Did you sleep well last night?”

C
Rationale: Nonadherence to anticonvulsant therapy is a common cause of breakthrough seizures.

Can phenytoin cause muscle incoordination?

Yes. Phenytoin commonly causes muscle incoordination (ataxia).

Key NCLEX associations with phenytoin:

• Ataxia (unsteady gait / poor coordination)

• Dizziness

• Slurred speech

• Nystagmus

• Diplopia

• Sedation

• Gingival hyperplasia

👉 NCLEX tip:
If you see unsteady walking, difficulty with coordination, or slurred speech in a patient taking phenytoin, think drug effect or toxicity, and implement safety precautions (fall risk).