The nurse suspects an older client is having a grand mal seizure. What is the nurse's highest priority?
1. To use the head-tilt/chin-lift method
2. To prevent the seizure from lasting more than five minutes
3. To document the progression of symptoms
4. To prevent the client from being injured
4. To prevent the client from being injured
Explanation: 1. The head-tilt/chin-lift method should be used to obtain an airway, if necessary.
2. It is not possible to stop a seizure once it has started; however, if one seizure lasts longer than 10 minutes, or several seizures occur back-to-back, lasting longer than 30 minutes, this is an emergency. The client should be given oxygen.
3. Although it is crucial to document the progression of symptoms, this is not the nurse's highest priority.
4. Although preventing injury from seizures is important in clients of all ages, it is especially so for older clients, due to the likely severity of the injury.
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