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    Ati Rn Adult Medical Surgical 2023 Proctored Exam

    A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following is the priority?

    Explanation & Rationale

    Rationale: A. Turn the client on their side: Positioning the client in a lateral (side-lying) position during a tonic-clonic seizure helps maintain a patent airway and allows secretions to drain, reducing the risk of aspiration. This action is a primary safety intervention that should be implemented immediately upon observing seizure activity. B. Obtain the client's vital signs: Vital signs are important for monitoring the client’s physiological status but are secondary to ensuring airway protection and safety during active seizure activity. Attempting to measure vitals during a seizure may delay essential interventions and place the nurse at risk of injury. C. Perform a neurologic check: A full neurologic assessment is performed after the seizure ends, during the postictal phase, to evaluate the client’s level of consciousness, motor function, and any residual deficits. It is not appropriate to conduct a detailed neurologic check during the seizure itself. D. Notify the rapid response team: Activating a rapid response is reserved for life-threatening events such as prolonged seizure (status epilepticus) or cardiopulmonary compromise. Most tonic-clonic seizures are self-limiting, and immediate focus should be on safety and airway management before calling for additional resources.

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