The client takes a walk in the hallway and the nurse is present as the client has a seizure. Rank the nursing interventions in order beginning with the first action the nurse should implement

Question

1. Remove nearby furniture.
2. Loosen restrictive clothing.
3. Maintain the client's airway.
4. Ease client to a safe location.

Answer 1

4, 3, 1, 2
4. Because the client is unsupported in the hallway, the nurse gently lowers the client to the floor to prevent injury from a fall.
3. The nurse cannot maintain the client's airway until the client is on a stable surface; because impaired airway is the client's greatest risk during a seizure, the airway is the nurse's second priority.
1. The nurse removes hazards to prevent client injury during the seizure.
2. Finally, the nurse loosens restrictive clothing to free the client of restraint; in addition, restrictive clothing can lead to skin breakdown as the client experiences the violent muscle contractions during a seizure.