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Difficulty: MediumAccident, Error, and Injury Prevention

A practical nurse (PN) is providing morning care for a client when the client suddenly loses consciousness and begins exhibiting generalized tonic-clonic muscle movements. Which action should the PN take first to prevent injury to the client?

  1. Turn the client onto their side and support their head on a soft surfaceAnswer
  2. B
    Insert a padded tongue blade between the teeth to protect the airway
  3. C
    Hold the client's extremities firmly to prevent them from striking the bedrails
  4. D
    Elevate the head of the bed to a high-Fowler's position to facilitate breathing

Answer

Turn the client onto their side and support their head on a soft surface.
The immediate priority during a seizure is to protect the airway and prevent trauma. Turning the client to a side-lying position allows saliva and emesis to drain, preventing aspiration. Simultaneously, supporting the head on a soft surface prevents blunt head trauma caused by the rhythmic, forceful muscle contractions.

Step-by-Step Solution

1
Recognize the onset of a tonic-clonic seizure.
The nursing priority shifts immediately to client safety and airway protection.
Tonic-clonic movements present a high risk for blunt trauma and aspiration of oral secretions.
2
Position the client laterally (side-lying).
Gravity facilitates the outward drainage of saliva and emesis.
This prevents aspiration, thereby maintaining airway patency (the primary ABC priority).
3
Place a soft pad or folded towel under the client's head.
The client's head is protected from repeatedly striking hard surfaces.
Convulsive movements are forceful and involuntary, which can easily cause severe cranial injury against the bed or floor.

Key Concept

Seizure Safety and Injury Prevention
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Topics

Accident, Error, and Injury Prevention

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