What should the nurse do for a client who experiences a seizure? ...

[K@]

What should the nurse do for a client who experiences a seizure?
 
  1. Insert a tongue blade into the client's mouth.
  2. Loosen any clothing around the neck and chest.
  3. Restrain the client.
  4. Turn the client to the supine position if possible.

Question 2

In which situation can the nurse apply restraints to a client?
 
  1. Client wanders around the care area
  2. Client is picking at the access site for intravenous infusion of chemotherapy
  3. Client needed to use the bathroom and waited for help but didn't want to soil the bed and fell while attempting to walk to the bathroom
  4. Client does not want to stay in bed but wants to sit in the lounge with others.

[katheyjon]

Answer to Question 1

Correct Answer: 2
Rationale 1: Research has found that more injury can occur to the client if the caregiver tries to place anything in the mouth during the seizure.
Rationale 2: Loosening any clothing around the neck and chest prevents constriction that might occur during the seizure that could compromise the airway.
Rationale 3: A client should never be restrained during a seizure. The nurse should stay with the client and call for assistance, if needed.
Rationale 4: If possible, the client should be turned onto the lateral position, not supine, to allow for any secretions to drain out of the mouth.

Answer to Question 2

Correct Answer: 2
Rationale 1: Restraints cannot be used for the convenience of the care staff.
Rationale 2: In this situation, the client's actions could hinder his/her health status and a restraint would be indicated.
Rationale 3: This situation would not call for the client to be restrained. The care staff needs to be more attentive to the client's needs.
Rationale 4: This client would not be a candidate for restraints.

[K@]

Thanks for the timely response, appreciate it

[phuda]

TYSM