The nurse is caring for a patient following surgery for a brain tumor. Three days after surgery, the LVN enters the room and finds the patient jerking rhythmically in the bed. The patient does not respond to the LVN's questions
What should the nurse do first?
a. Go find the RN to assist.
b. Hold the patient firmly to keep the patient from injuring someone.
c. Call the physician.
d. Protect the patient from injury and observe the sequence of events.
ANS: D
The prime objective in caring for a patient experiencing a seizure is to prevent injury to the patient. Once the patient's safety has been assured, the RN can be summoned and the physician if necessary. Holding the patient increases risk of injury.
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