A male client is having tonic-clonic seizures. What should the nurse do first?
A. Elevate the head of the bed.
B. Restrain the client’s arms and legs.
C. Place a tongue blade in the client’s mouth.
D. Take measures to prevent injury.
Correct Answer: D. Take measures to prevent injury.
Protecting the client from injury is the immediate priority during a seizure. Do not leave the patient during and after a seizure to promote safety measures. 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. Loosen clothing from neck or chest and abdominal areas to aid in breathing or chest expansion.
Option A: Elevating the head of the bed would have no effect on the client’s condition or safety. Support the head, place on soft areas or assist to the floor if out of bed. Supporting the extremities lessens the risk of physical injury when the patient lacks voluntary muscle control.
Option B: Restraining the client’s arms and legs could cause injury. Do not attempt to restrain. If the attempt is made to restrain the patient during a seizure, erratic movements may increase, and the patient may injure himself or others.
Option C: Placing a tongue blade or other object in the client’s mouth could damage the teeth. 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.
No comments:
Post a Comment