The nurse is bathing a client who suddenly begins to display tonic-clonic muscle activity. The client does not have a history of seizures. After providing for the client's safety, what is the nurse's priority of care?
1. Assess vital signs.
2. Time the seizure.
3. Complete the bath.
4. Cover the client with a blanket.
2
Rationale: The nurse's priority is to time the seizure, because the provider will want to know how long it lasted and what occurred during the seizure. The nurse will carefully document what was observed, the length of time the seizure continued, and the client's condition after the seizure subsided. It is not safe to restrain the client to obtain vital signs during the seizure, and placement of a blanket would be futile because it would be kicked off by the clonic tonic movements. The nurse will not complete the bath but will change the plan of care based on the change in the client's status.
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