A head-injured patient is presenting with a generalized seizure. An appropriate nursing intervention during the seizure would include which of the following?
A) Restrain the patient to prevent injury.
B) Open the patient's jaws to insert an oral airway.
C) Place patient in high-Fowler's position.
D) Loosen the patient's restrictive clothing.
Ans: D
Feedback: An appropriate nursing intervention would include loosening any restrictive clothing on the patient. No attempt should be made to restrain the patient during the seizure because muscular contractions are strong and restraint can produce injury. Jaws that are clenched in a spasm should not be pried open to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. Refer to Chart 61-4, page 1875.
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