A nurse is contributing to the plan of care for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

A. Aura phase:

The aura phase occurs before the seizure and is characterized by subjective sensations or experiences that some individuals may have. It serves as a warning sign that a seizure is about to occur. This phase precedes the seizure itself and is not applicable to the period immediately afterward.

B. Presence of automatisms:

Automatisms refer to repetitive, involuntary movements or actions that some individuals may exhibit during certain types of seizures, such as complex partial seizures. They are not typically observed during the postictal phase of a generalized tonic-clonic seizure.

C. Postictal phase:

The postictal phase, also known as the postictal state, refers to the period following a seizure during which the individual may experience confusion, drowsiness, or other altered states of consciousness. This phase typically lasts for minutes to hours and is characterized by gradual recovery of normal function.

D. Presence of absence seizures:

Absence seizures are characterized by brief episodes of altered consciousness, often manifesting as staring spells or momentary loss of awareness. They are distinct from generalized tonic-clonic seizures and do not involve the same postictal phase characterized by drowsiness and altered arousal.

A. Withhold the next dose and notify the physician:

Withholding the next dose of the cholinergic agent is the appropriate immediate action because the presence of inspiratory and expiratory wheezing bilaterally suggests bronchoconstriction or bronchospasm, which can be a serious adverse reaction to the medication. Notifying the physician promptly allows for further assessment and management of the patient's respiratory symptoms. The physician may need to adjust the medication regimen, order diagnostic tests, or provide treatment for bronchoconstriction.

B. Give the next dose:

Administering the next dose of the cholinergic agent could worsen the patient's respiratory symptoms and exacerbate bronchoconstriction. This action is contraindicated in the presence of wheezing, as it may further compromise the patient's respiratory function.

C. Assess heart rate:

While assessing heart rate is an important aspect of patient assessment, it is not the priority in this scenario. The priority is to address the respiratory distress and potential bronchoconstriction associated with the cholinergic agent. Wheezing is a respiratory symptom that suggests airway obstruction, and immediate intervention is necessary to ensure adequate oxygenation and ventilation.

D. Assess blood pressure:

Similarly, while assessing blood pressure is important in patient care, it is not the priority in this situation. The priority is to address the respiratory distress and potential bronchoconstriction associated with the cholinergic agent. Wheezing indicates respiratory compromise, and prompt action is required to prevent further respiratory deterioration.