A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

Choice A reason: Gently restraining extremities during a tonic-clonic seizure is unsafe, as it can cause injury or increase muscle strain. The clonic phase involves rhythmic jerking, and restraint may lead to fractures or soft tissue damage. Protecting the client by cushioning the head and ensuring safety is the priority. Choice B reason: Placing a client on a BiPAP machine during a seizure is impractical and unsafe. The clonic phase involves uncontrolled movements, making BiPAP application impossible. Post-seizure, oxygenation may be needed, but during the seizure, protecting the client from injury, like head trauma, takes precedence. Choice C reason: Placing a pillow under the client’s head during a tonic-clonic seizure protects against head injury from repetitive clonic movements against the floor. This action ensures safety by cushioning the head, reducing the risk of trauma or skull fracture, which is a priority during active seizure activity. Choice D reason: Inserting a padded tongue blade is contraindicated during a seizure, as it risks injury to the mouth or airway obstruction. The jaw is often clenched in the clonic phase, and forcing objects into the mouth can cause dental damage or aspiration, making this an unsafe intervention.