A nurse is caring for a child who is having a seizure.Which of the following actions should the nurse take? (Select all that apply.)
Explanation & Rationale
The correct answers are B. Assess the client’s airway patency,C. Remove objects from the client’s bed, and D. Place the client in a side-lying position.Choice A rationaleRestraining the client during a seizure is not recommended as it can cause injury. The focus should be on ensuring the client’s safety and preventing harm.Choice B rationaleAssessing the client’s airway patency is crucial during a seizure to ensure that the client is breathing properly and that the airway is not obstructed.Choice C rationaleRemoving objects from the client’s bed helps prevent injury during a seizure. Objects in the bed can pose a risk of harm if the client hits them during the seizure.Choice D rationalePlacing the client in a side-lying position helps maintain an open airway and reduces the risk of aspiration. This position allows any secretions to drain out of the mouth, preventing choking.Choice E rationalePlacing a tongue depressor in the client’s mouth is not recommended and can cause injury. It is a common misconception that this prevents the client from swallowing their tongue, but it can actually cause more harm.