The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated?
A. Loosening restrictive clothing.
B. Restraining the client’s limbs.
C. Removing the pillow and raising padded side rails.
D. Positioning the client to the side, if possible, with the head flexed forward.
Correct Answer: B. Restraining the client’s limbs.
The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed.
Option A: Nursing actions during a seizure include providing for privacy and loosening restrictive clothing. Loosen clothing from neck or chest and abdominal areas. Aids in breathing or chest expansion. Maintain in lying position, flat surface; turn head to side during seizure activity. Helps in the drainage of secretions; prevents the tongue from obstructing the airway.
Option C: Use and pad side rails with the bed in lowest position, or place the bed up against the wall and pad floor if rails are not available or appropriate. Prevents or minimizes injury when seizures (frequent or generalized) occur while the patient is in bed. Note: Most individuals seize in place and if, in the middle of the bed, the individual is unlikely to fall out of bed.
Option D: Turn head to side and suction airway as indicated. Insert plastic bite blocks only if the jaw relaxed. Helps maintain airway patency and reduces the risk of oral trauma but should not be “forced” or inserted when teeth are clenched because dental and soft-tissue damage may result. Note: Wooden tongue blades should not be used because they may splinter and break in the patient’s mouth.
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