Soru

Zorluk: OrtaAccident, Error, and Injury Prevention

During a group activity session in the facility lounge, a client seated in a wheelchair suddenly develops a generalized tonic-clonic seizure. Arrange the following safety interventions in the chronological order the practical nurse (PN) should implement them, from first to last.

  1. 1Guide the client carefully from the wheelchair down to the ground.
  2. 2Place a flat, soft cushion or folded garment beneath the client's head.
  3. 3Loosen any restrictive clothing, such as a buttoned collar, around the client's neck.
  4. 4Roll the client into a lateral position to prevent aspiration of secretions.

Cevap

The correct sequence is to first guide the client to the floor, then protect their head, followed by loosening restrictive clothing, and finally rolling them onto their side.
During a seizure, the primary goal is to prevent injury. The first action is to safely ease the client to the floor to prevent a sudden, uncontrolled fall. Next, the nurse must protect the head from trauma using a soft cushion or barrier. Then, restrictive clothing around the neck is loosened to prevent airway compromise. Finally, placing the client in a side-lying (lateral) position promotes drainage of oral secretions and prevents aspiration.

Adım Adım Çözüm

1
Address the most immediate risk of injury from falling.
The nurse assists the client from the wheelchair to the floor.
A client having a seizure in a chair is at high risk for a traumatic fall. Easing them to the ground minimizes this drop.
2
Protect the client from blunt force trauma caused by the seizing movements.
The nurse places a soft barrier under the client's head.
The head is highly vulnerable to injury from striking the floor during tonic-clonic movements.
3
Eliminate external restrictions to breathing.
The nurse loosens tight clothing around the neck.
Neckties, tight collars, or scarves can restrict the airway or blood flow as the client's muscles contract.
4
Maintain internal airway patency.
The nurse positions the client on their side.
The lateral position prevents the tongue from blocking the airway and allows saliva or emesis to drain out of the mouth, preventing aspiration.

Anahtar Kavram

Seizure Safety and Injury Prevention
Bu soruyu puanla