The nurse documents the following after observing a client have a tonic-clonic seizure: “0930 Found client having jerky, involuntary movements of upper and lower extremities lasting 2 minutes, frothy saliva oozing from mouth, incontinent of urine.” Which statement best describes the nurse’s documentation? The documentation:
a. is appropriate and describes the observations seen.
b. should include the client’s response and nursing interventions.
c. should just indicate that the client had a tonic-clonic seizure.
d. is lacking whether the client had an aura experience before the seizure.
Rationale:
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