A patient without a history of previous seizures experiences two tonic-clonic seizures in succession while the nurse is in the patient's room. List in priority order the actions the nurse should take
Click and drag the options below to move them up or down. Choice 1. Turn the patient on his or her side.
Choice 2. Protect the patient from environmental harm.
Choice 3. Start oxygen via face mask.
Choice 4. Reorient the patient to time, person, and place.
1,2,3,4
Rationale 1: Nursing care of patients during a seizure should first focus on maintaining a patent airway. During a seizure, the tongue may fall back and obstruct the airway, the gag reflex may be depressed, and secretions may pool at the back of the throat. To open and maintain a patent airway, the patient should be turned on his or her side.
Rationale 2: After ensuring the airway is patent, the nurse should protect the patient from harm.
Rationale 3: After the clonic phase of seizure activity, if needed, oxygen can be administered by face mask.
Rationale 4: Consciousness returns gradually. It may take hours before the patient is fully aware and alert and reorientation to person, place, and time can be achieved.
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