The nurse is caring for a client who has seizure precautions. Which actions by the nurse are appropriate for these precautions?
1. Padding the bed around the head, foot, and side rails
2. Placing functional oral suction equipment in the room
3. Placing extremity restraints in the room for use if the client has a seizure
4. Keeping pillows handy to protect the client's head
5. Taping a bite block to the wall to protect the client from biting his or her tongue
1,2,4
Rationale 1: Padding the bed will protect the client from injury if tonic–clonic movement of the extremities occurs during a seizure.
Rationale 2: Suctioning equipment will allow the nurse to clear the airway after the seizure.
Rationale 3: The client's extremities should never be restrained during a seizure.
Rationale 4: Pillows are useful in helping the client protect the head from banging on the floor if he is not in bed when a seizure occurs.
Rationale 5: Nothing should be inserted into the client's mouth during a seizure, so bite blocks are not necessary.
Global Rationale: Padding the bed will protect the client from injury if clonic tonic movement of the extremities occurs during a seizure. Suctioning equipment will allow the nurse to clear the airway after the seizure. Pillows are useful in helping the client protect the head from banging on the floor if he is not in bed when a seizure occurs. The client's extremities should never be restrained during a seizure. Nothing should be inserted into the client's mouth during a seizure, so bite blocks are not necessary.
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