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Difficulty: MediumAccident, Error, and Injury Prevention

During an environmental safety audit on a medical-surgical unit, the charge nurse evaluates the room setup and care plan for a client admitted with uncontrolled generalized tonic-clonic seizures. Which of the following documented interventions confirm that appropriate injury prevention measures have been implemented? Select all that apply.

  1. Verifying that wall suction apparatus and a bag-valve-mask device are functioning at the bedsideAnswer
  2. B
    Delegating the immediate post-ictal neurological assessment to an unlicensed assistive personnel (UAP)
  3. Padding the side rails of the bed using facility-approved protective materialsAnswer
  4. D
    Obtaining a prescription for soft wrist restraints to prevent the client from thrashing during active seizure activity
  5. Ensuring that the bed is maintained in the lowest possible position with the wheels lockedAnswer
  6. F
    Positioning the client strictly in a supine position after the seizure ceases to facilitate rapid airway clearance

Answer

The correct injury prevention measures for a client with seizure risk include verifying functional airway equipment (suction and bag-valve-mask) at the bedside, padding the bed's side rails, and keeping the bed in the lowest locked position.
The appropriate safety protocol for seizure risk prioritizes airway management and physical protection. Keeping suction and oxygenation equipment at the bedside ensures immediate readiness if the airway becomes compromised. Padding the side rails protects the client's head and extremities from blunt trauma during tonic-clonic movements. Maintaining the bed in the lowest locked position minimizes the distance to the floor and prevents the bed from shifting, significantly reducing the risk of a severe fall injury.

Step-by-Step Solution

1
Identify the primary safety risks associated with generalized tonic-clonic seizures.
Recognize that risks include airway compromise, aspiration of secretions, and traumatic physical injury from involuntary movements or falls.
Understanding the specific pathophysiology of the hazard dictates which environmental and clinical safety protocols are required.
2
Select proactive interventions that protect the airway and physical environment without causing secondary harm.
Equipment preparation (suction/oxygen), physical cushioning (padded rails), and fall distance minimization (low locked bed) are identified as correct.
These actions create a safe space that accommodates the seizure rather than dangerously attempting to halt the physical movements.
3
Eliminate interventions that violate safety principles or scope of practice.
Reject the use of physical restraints, supine post-ictal positioning, and the delegation of assessments to unlicensed personnel.
Restraints cause fractures during seizures, supine positioning causes aspiration, and UAPs are not licensed to perform post-ictal neurological assessments.

Key Concept

Seizure Precautions and Injury Prevention
Estimated Time:1m 30s
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Topics

Accident, Error, and Injury Prevention

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