The nurse is planning care for a client with a seizure disorder and selects risk for injury as a nursing diagnosis. Which of the following nursing interventions is planned if the client has a seizure?

Question

1. Insert a tongue blade into the client's mouth
2. Loosen any clothing around the neck and chest
3. Restrain the client
4. Turn the client to the supine position if possible

Answer 1

2. Loosen any clothing around the neck and chest

Rationale:
Loosening any clothing around the neck and chest during the seizure prevents possible constriction that could compromise the airway. Research has found that more injury can occur to the client if the caregiver tries to place something in the mouth during the seizure than if the caregiver does not. A client should never be restrained during a seizure. The nurse should stay with the client and call for assistance, if needed. If possible, the client should be turned onto the lateral position, not supine, to allow for any secretions to drain out of the mouth.