ATI PN Comprehensive Predictor 2023 - Proctored Exam 1
A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Lower the side rails of the bed when the seizure begins. Measure the duration of the seizure. Restrain the client's arms and legs to prevent injury. Insert an oral airway into the client's mouth.
Explanation & Rationale
Lowering the side rails of the bed could lead to the client falling from the bed. Instead raise the side rails and place padding on them. Measuring the seizure duration is a crucial step for medical evaluation afterwards necessary for determining intervention. Inserting an oral airway into the client's mouth is not indicated during a tonic-clonic seizure. It is generally not recommended to place any objects or devices into the mouth of a person having a seizure, as it can potentially cause injury to the person or damage to the airway.
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