A client with a history of epilepsy suddenly begins to experience a generalized tonic-clonic seizure while sitting in a bedside chair. To prevent injury, in what order should the practical nurse perform the following actions? (Arrange the actions from first to last.)
- 1Carefully guide the client from the chair down to the floor.
- 2Place a soft pad or folded blanket under the client's head.
- 3Turn the client onto their side in a lateral position.
- 4Loosen any tight or restrictive clothing around the client's neck.
- 5Note the exact time the seizure began and monitor its duration.
Cevap
The correct sequence of actions for a client having a seizure in a chair is to first safely guide them to the floor, protect their head, turn them on their side to protect the airway, loosen restrictive clothing, and finally note the time and duration.
During a generalized tonic-clonic seizure, the nurse's primary goal is to prevent physical injury and maintain a patent airway. The nurse must first safely lower the client to the floor to prevent a traumatic fall from the chair. Next, the head must be protected from striking the floor. The client is then rolled onto their side to allow saliva or emesis to drain, preventing aspiration. Loosening tight clothing further supports respiratory function. Once the client is physically secure and breathing safely, the nurse notes the exact time to monitor the seizure's duration and document the clinical event.
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Anahtar Kavram
Seizure Safety and Injury Prevention
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