The nurse has just entered a client's room and the client is experiencing a tonic-clonic seizure. Which of the following nursing interventions are appropriate for this client? (Select all that apply.)

Question

a. Assess the client's respiratory status.
b. Note time on onset and duration.
c. Document if client is unconscious.
d. Position the client on back to open airway.
e. Prepare suction equipment
f. Pad the siderails with blankets for safety
g. Hold the client down to prevent injury
h. Loosen restrictive clothing

Answer 1

A, B, C, E, F, H
During a seizure it is important to assess a client's respiratory status. The client should be turned to the side to prevent the pooling of secretions. The nurse should prepare to suction the oropharynx if necessary to clear the airway. During the seizure, assess the client's respiratory status and observe for muscular stiffness or flaccidity, the position of the eyes and head, the size and equality of the pupils, automatism, any cry or sounds made, and incontinence of urine or stool. Note the duration of the phases of the seizure, total duration, and whether unconsciousness occurred. Note if the onset of seizure activity was observed, along with what the client was doing when the seizure began. To prevent injury, the siderails of the bed should be padded and the nurse should loosen restrictive clothing.