A client is experiencing status epilepticus. The nurse should:
a. turn the client on the back and insert a tongue blade in the mouth.
b. ensure a patent airway and protect the client's head and body from injury.
c. move the client to a bed and restrain the extremities.
d. raise all side rails and restrain the extremities.
ANS: B
Feedback
A Incorrect: Nothing should be inserted in the client's mouth after a seizure has begun.
B Correct: These are the nurse's priorities.
C Incorrect: The client should only be moved to protect them from the environment, but the client should not be restrained.
D Incorrect: As noted previously, the client should not be restrained. The side rails should be padded.
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