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?
Explanation & Rationale
A. Measure the duration of the seizure. This is the correct action. Monitoring the duration of the seizure is important for assessing its severity and deciding when to intervene medically. A seizure lasting longer than 5 minutes requires immediate intervention. B. Lower the side rails of the bed when the seizure begins. This is not recommended. The side rails should be raised to protect the client from injury. Lowering them could increase the risk of falling out of bed. C. Insert an oral airway into the client's mouth. This is incorrect. Inserting an airway into the mouth during a seizure can be dangerous and may result in injury to the client or the nurse. The client’s airway should be kept clear, but inserting an object into the mouth is not recommended. D. Restrain the client's arms and legs to prevent injury. This is incorrect. Restraining the client during a seizure can cause injury to both the client and the nurse. It is better to allow the seizure to proceed naturally while ensuring the client is protected from injury (e.g., by placing a soft pillow under their head or cushioning hard surfaces around them).