A child is being prepared for a computed tomography (CT) scan when the child begins to have a tonic-clonic seizure. The mother is hysterical and is trying to hold the child down. Which action(s) should the nurse take? (Select all that apply)
Explanation & Rationale
Choice A reason: Pillows inside side rails protect the child from injury during a seizure by cushioning thrashing limbs, a standard safety measure until the episode subsides. Choice B reason: Monitoring airway and tongue ensures breathing isn’t obstructed by saliva or tongue position, critical during a tonic-clonic seizure to prevent hypoxia. Choice C reason: Asking the mother to release the child prevents restraint-related injury; uncontrolled holding risks harm, and the nurse needs access for safe management. Choice D reason: Darkening the room reduces stimuli but isn’t urgent; safety and airway take priority over environmental adjustments during an active seizure event. Choice E reason: Anticonvulsants require a prescription and time; nurses can’t administer without orders during an acute seizure, making it impractical as an immediate action.