# A 36-year-old client with epilepsy was admitted this morning after missing 2 days of levetiracetam because of vomiting; admission serum sodium was 138 mEq/L. At 1412 the nurse finds the client having generalized, rhythmic, synchronous jerking of all 4 extremities with eyes open and deviated to the right. At 1418 the jerking continues, and the client has not responded to voice or touch at any point since 1412. Oxygen saturation has fallen from 96% to 86% despite side-lying positioning and jaw thrust, heart rate is 132/min, and blood pressure is 158/92 mm Hg. Point-of-care glucose is 104 mg/dL. A peripheral IV is patent. The client has bitten the tongue and has been incontinent of urine. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617369&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A 36-year-old client with epilepsy was admitted this morning after missing 2 days of levetiracetam because of vomiting; admission serum sodium was 138 mEq/L. At 1412 the nurse finds the client having generalized, rhythmic, synchronous jerking of all 4 extremities with eyes open and deviated to the right. At 1418 the jerking continues, and the client has not responded to voice or touch at any point since 1412. Oxygen saturation has fallen from 96% to 86% despite side-lying positioning and jaw thrust, heart rate is 132/min, and blood pressure is 158/92 mm Hg. Point-of-care glucose is 104 mg/dL. A peripheral IV is patent. The client has bitten the tongue and has been incontinent of urine. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Seizure cluster with recovery between events
Convulsive status epilepticus
Psychogenic nonepileptic seizure
Hyponatremic seizure from vomiting

Actions to take

Select 2
Administer the prescribed IV lorazepam now
Give the prescribed 3% sodium chloride bolus
Arrange a head CT before giving medication
Give oxygen by nonrebreather mask and suction
Insert an oral airway between the clenched teeth

Parameters to monitor

Select 2
Serum sodium level every 4 hours
Serum creatine kinase
Duration of seizure activity
Serum levetiracetam level
Respiratory rate and SpO2

## Explanation

Continuous generalized convulsive activity for 5 minutes or longer without any return of responsiveness is convulsive status epilepticus, here provoked by missed levetiracetam rather than a metabolic cause. An immediate first-line benzodiazepine is given while oxygen and suction support the airway. Seizure duration and respiratory status (including benzodiazepine-related respiratory depression) show whether treatment is working.

## In-depth explanation

Quick answer
Convulsive status epilepticus. Actions: give the prescribed IV lorazepam now; give oxygen by nonrebreather mask and suction. Monitor: duration of seizure activity, and respiratory rate with oxygen saturation.

Why this is correct
Seizure activity continuing beyond 5 minutes, or repeated seizures without recovery between them, is status epilepticus. From 1412 to 1418 the jerking has not stopped and the client has not responded at any point. Eyes-open, synchronous jerking with tongue biting, incontinence, and falling saturation is epileptic. Missed levetiracetam is the likely trigger; a glucose of 104 mg/dL and a sodium of 138 mEq/L do not point to a metabolic cause. The time-critical treatment is a benzodiazepine now, with airway support, because the longer seizures last the more drug-resistant they become.

Easy analogy or mental picture
Think of a fire that has been burning 5 minutes: you spray the extinguisher (benzodiazepine) and open a window for air (oxygen and suction) at the same time, and you keep watching the clock and the smoke.

Memory hook
5 minutes = status. Benzo now, airway always, watch the clock and the breathing.

NCLEX decision rule
When the diagnosis is made by time, act on time: give the first-line drug immediately and support the airway; do not delay treatment for imaging or place objects in the mouth.

Why the other choices are wrong
A seizure cluster requires recovery between seizures; this client has not responded at any point. Psychogenic events typically have eyes closed, asynchronous movements, and preserved oxygenation. Hyponatremic seizures need a low sodium, and the admission sodium is 138 mEq/L, so hypertonic saline and sodium checks target the wrong problem. A head CT may be needed later but must not delay treatment. An oral airway forced between clenched teeth can break teeth and injure the mouth; jaw thrust, suction, and oxygen support the airway instead. Creatine kinase and a levetiracetam level are useful later but do not show whether the seizure is being controlled right now.

References
1American Epilepsy Society — Guideline for Treatment of Convulsive Status Epilepticus (ACEP endorsed)Benzodiazepine as initial therapy at 5 minutes, followed by a second-line agent if seizures persist.

## Clinical scenario

Scenario
A client with epilepsy who missed levetiracetam doses has continuous generalized convulsive activity for 6 minutes without responding at any point and falling oxygen saturation; glucose and admission sodium are normal.

## Key concepts

- **Status epilepticus** — Seizure activity lasting 5 minutes or more, or repeated seizures without return to baseline between them.
- **First-line benzodiazepine** — An IV, IM, or intranasal benzodiazepine given immediately to stop status epilepticus.
- **Seizure cluster** — Several seizures close together with recovery of responsiveness between them, distinct from status epilepticus.

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