Question

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions by the nurse would be contraindicated? Select all that apply.

1.Restrain the client's limbs. 2.Loosen restrictive clothing. 3.Consider insertion of a padded tongue blade. 4.Remove the pillow and raise the padded side rails. 5.Position the client to the side, if possible, with head flexed forward.

Answer 1

Interventions contraindicated during a seizure include restraining the client's limbs and inserting a padded tongue blade. Instead, the nurse should ensure the patient's safety by loosening clothing, adjusting the bed safety features, and positioning the patient. Anticonvulsants are sometimes used to manage seizures and might follow such an event.

Step-by-step explanation:

When caring for a client experiencing a seizure, certain interventions are contraindicated. It is important not to restrain the client's limbs (Option 1), as this can cause injury and does not stop the seizure activity. Additionally, inserting a padded tongue blade (Option 3) is a dated practice that is no longer recommended because it can cause mouth or teeth injuries and poses a choking hazard. Instead, the nurse should focus on actions that promote safety and prevent injury, such as loosening restrictive clothing (Option 2), removing the pillow and raising padded side rails to prevent falls (Option 4), and positioning the client to the side, if possible, with head flexed forward to aid with breathing and prevent aspiration (Option 5). Medications like anticonvulsants may be administered to manage seizures, especially in patients with conditions such as epilepsy, and are critical in improving long-term prognosis and reducing the risk of brain damage from recurrent seizures.