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Question

Difficulty: MediumAccident, Error, and Injury Prevention

The nursing care team is preparing a room for a client diagnosed with epilepsy who experiences frequent, unpredictable generalized tonic-clonic seizures. Which environmental modifications and safety practices should be established immediately? Select all that apply.

  1. Set up functioning suction equipment and supplemental oxygen at the bedside.Answer
  2. Apply facility-approved padding to the side rails of the client's bed.Answer
  3. Maintain the bed in the lowest possible position with the casters securely locked.Answer
  4. D
    Place a padded tongue blade at the bedside for insertion during a convulsion.
  5. E
    Assign a room at the far end of the unit to decrease sensory stimulation.
  6. F
    Assign the nursing assistant to perform and document the client's baseline neurological evaluation upon arrival.

Answer

The correct actions are setting up suction and oxygen, padding the side rails, and keeping the bed in the lowest locked position.
Effective seizure precautions focus on anticipating airway needs and creating a safe physical perimeter. Preparing suction and oxygen ensures immediate response to respiratory compromise. Padded side rails protect the extremities and head during involuntary motor activity, while a low, locked bed prevents secondary fall injuries.

Step-by-Step Solution

1
Identify the primary risks associated with generalized tonic-clonic seizures.
The main risks are airway compromise (from secretions or vomitus) and physical injury (from violent movements or falls).
Understanding the pathophysiology of the condition dictates the required environmental safety measures.
2
Select interventions that protect the airway and prevent blunt trauma.
Padding the rails, keeping the bed low, and preparing suction/oxygen directly mitigate these specific risks.
These are universally accepted, evidence-based seizure precautions.
3
Eliminate interventions that are outdated, harmful, or violate nursing scope of practice.
Rejecting the use of bite blocks/tongue blades, avoiding remote room placement, and ensuring the RN performs the assessment.
Adhering to current safety guidelines prevents iatrogenic injury and ensures legal compliance.

Key Concept

Seizure Precautions and Environmental Safety
Estimated Time:1m 30s
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Topics

Accident, Error, and Injury Prevention

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