A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
Explanation & Rationale
A. Use a padded tongue blade to protect the client's tongue while seizing: A tongue blade should not be used during a seizure, as it can cause injury to the client. The client’s airway should be protected by positioning them correctly, not by inserting objects into their mouth. B. Place the client in a supine position during the seizure: The client should not be placed in a supine position during a seizure due to the risk of aspiration. Instead, the client should be placed on their side to help maintain an open airway and prevent aspiration. C. Monitor the client's respiratory and cardiac status: During a tonic-clonic seizure, respiratory and cardiac monitoring are crucial. Seizures can lead to decreased oxygenation, irregular heart rhythms, and other complications. D. Offer the client a cup of juice to drink once the seizure is over: After a seizure, the client may have impaired swallowing reflexes, and offering liquids too soon can cause aspiration. The nurse should assess the client’s ability to swallow before offering fluids.