The nurse is assisting a client with a known seizure disorder to ambulate down the unit hallway. Suddenly, the client loses consciousness, their body stiffens, and they begin to experience a generalized tonic-clonic seizure. Which of the following is the nurse's immediate priority action to prevent client injury?
- AKeep the client in a standing position and urgently carry them back to their hospital bed.
- Ease the client safely to the floor and place a soft cushion or rolled blanket under their head.Answer
- CFirmly hold the client's arms and legs against their body to prevent them from striking the floor.
- DDirect the unlicensed assistive personnel (UAP) to retrieve and immediately insert a padded tongue blade.
Answer
The correct action is to ease the client safely to the floor and place a soft cushion or rolled blanket under their head.
The immediate priority during a tonic-clonic seizure, especially when the client is standing or walking, is to prevent trauma from a fall. Easing the client to the floor and protecting their head from striking hard surfaces directly mitigates the highest risk of acute injury.
Step-by-Step Solution
Key Concept
During an active seizure, nursing priorities focus on injury prevention by clearing the environment, safely lowering the client to the floor, protecting the head, and avoiding any physical restraint or insertion of objects into the mouth.
Estimated Time:1m 0s