A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse?
A) Insert an airway or bite block.
B) Manually restrain the extremities.
C) Turn client to side-lying position.
D) Monitor vital signs.
C
Feedback:
When a client begins to convulse, the highest priority is to maintain airway. This can best be accomplished by turning client to side-lying position, which allows saliva and emesis to drain from the mouth. Turning the client also allows the tongue to fall forward opening the airway. More damage can occur if a bite block is inserted after the seizure has begun. Manually restraining extremities is not recommended. Attempting to take B/P is not recommended and pulse rate and respirations during the event will not be beneficial. Monitor vital signs during the postictal phase.
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