A practical nurse (PN) is assisting a client who is sitting in a bedside chair to eat breakfast. The client suddenly loses consciousness and begins to experience a tonic-clonic seizure. In what order should the PN perform the following actions? (Arrange from first action to last)
- 1Assist the client safely to the floor and clear the immediate area of furniture.
- 2Place a soft pad or folded towel under the client's head.
- 3Turn the client onto one side to maintain an open airway.
- 4Record the time the seizure began and observe the characteristics of the movements.
Answer
The correct sequence is to first lower the client safely to the floor, protect their head with a soft pad, turn them onto their side to secure the airway, and finally time and observe the seizure activity.
During a seizure, the primary nursing goals are to prevent injury and maintain a patent airway. The sequence must prioritize immediate physical safety by getting the client to the floor to prevent an uncontrolled fall, followed immediately by protecting the most vulnerable body part (the head). Once physical trauma risks are minimized, the nurse addresses airway patency by turning the client on their side to prevent aspiration. Only after physical safety and the airway are fully secured does the nurse focus on observation and documentation.
Step-by-Step Solution
Key Concept
Seizure Precautions and Injury Prevention