A nurse enters the room of a patient who is sitting in a chair and begins to have a seizure. To promote patient safety, which nursing intervention will the nurse initially perform?

Question

a. Immediately call for assistance.
b. Assist the patient to the floor.
c. Put the patient back into the bed.
d. Insert a padded tongue blade into the patient's mouth.

Answer 1

B
When the seizure begins, position the patient safely. If the patient is standing or sitting, guide the patient to the floor and protect the head by cradling in the nurse's lap or placing a pillow under the head. Clear the surrounding area of furniture. If the patient is in bed, raise the side rails and pad, and put the bed in a low position. Stay with the patient, and observe the sequence and timing of seizure activity. Continued observation ensures adequate ventilation during and after a seizure and will assist in documentation, diagnosis, and treatment of a seizure disorder. If possible, turn the patient onto one side, with the head tilted slightly forward. This allows the tongue to fall away from the airway, permitting drainage of saliva and vomitus, and prevents aspiration. Do not force any objects such as fingers, medicine or tongue depressor, or airway into the patient's mouth when the teeth are clenched. This could cause injury to the mouth and stimulate gagging, which could lead to aspiration.