Question

A young adult is hospitalized with a seizure disorder. The client, who is in a bed with padded side rails, has a tonic-clonic seizure. In what order from first to last should the nurse take the actions?

A. Protect the client's head
B. Move the client to one side
C. Loosen constrictive clothing
D. Document the details of the seizure

Answer 1

The nurse should first protect the patient's head during a seizure, then position the patient on one side, loosen any restrictive clothing, and lastly document the seizure details.

Step-by-step explanation:

When a young adult is hospitalized with a seizure disorder and experiences a tonic-clonic seizure, the nurse should prioritize interventions in the following order to ensure patient safety and provide appropriate care:

1. Protect the client's head - To prevent injury during the seizure.
2. Move the client to one side - This helps to maintain an open airway and allows secretions or vomitus to drain effectively.
3. Loosen constrictive clothing - To prevent further restriction of breathing or circulation.
4. Document the details of the seizure - After the seizure has ended and the client is safe, the nurse should record the duration, type of movements, and any other observations relevant to the seizure.

Note that anticonvulsants may be administered, such as diazepam, to manage seizures and improve long-term prognosis. This is typically done by medical professionals rather than self-administered, as it's intended for actively seizing patients.