The nurse answers a call bell and finds a frightened mother whose child, the patient, is having a seizure. Which of these actions should the nurse take?
A. The nurse should insert a padded tongue blade in the patient’s mouth to prevent the child from swallowing or choking on his tongue.
B. The nurse should help the mother restrain the child to prevent him from injuring himself.
C. The nurse should call the operator to page for seizure assistance.
D. The nurse should clear the area and position the client safely.
Correct Answer: D. The nurse should clear the area and position the client safely.
The primary role of the nurse when a patient has a seizure is to protect the patient from harming him or herself. Support head, place on soft area or assist to the floor if out of bed. Supporting the extremities lessens the risk of physical injury when the patient lacks voluntary muscle control.
Option A: Provide and insert plastic airway or soft roll as indicated and only if the jaw is relaxed. If inserted before the jaw is tightened, these devices may prevent biting of the tongue and facilitate suctioning or respiratory support if required.
Option B: Do not attempt to restrain. If the attempt is made to restrain the patient during a seizure, erratic movements may increase, and the patient may injure self or others. Do not leave the patient during and after a seizure.
Option C: After keeping the patient safe, the nurse may call for help. Maintain in lying position, flat surface; turn head to side during seizure activity. This helps in the drainage of secretions; prevents the tongue from obstructing the airway.