During a group activity session in the facility lounge, a client seated in a wheelchair suddenly develops a generalized tonic-clonic seizure. Arrange the following safety interventions in the chronological order the practical nurse (PN) should implement them, from first to last.
- 1Guide the client carefully from the wheelchair down to the ground.
- 2Place a flat, soft cushion or folded garment beneath the client's head.
- 3Loosen any restrictive clothing, such as a buttoned collar, around the client's neck.
- 4Roll the client into a lateral position to prevent aspiration of secretions.
Answer
The correct sequence is to first guide the client to the floor, then protect their head, followed by loosening restrictive clothing, and finally rolling them onto their side.
During a seizure, the primary goal is to prevent injury. The first action is to safely ease the client to the floor to prevent a sudden, uncontrolled fall. Next, the nurse must protect the head from trauma using a soft cushion or barrier. Then, restrictive clothing around the neck is loosened to prevent airway compromise. Finally, placing the client in a side-lying (lateral) position promotes drainage of oral secretions and prevents aspiration.
Step-by-Step Solution
Key Concept
Seizure Safety and Injury Prevention