A 2-year-old starts to have a tonic-clonic (grand mal) seizure while in a crib in the hospital. The child's jaws are clamped. The most important nursing action at this time is which of the following?
1. Place a padded tongue blade between the child's jaws
2. Stay with the child and observe the respiratory status
3. Prepare the suction equipment
4. Restrain the child to prevent injury
2. Stay with the child and observe the respiratory status
Rationale:
During a seizure the nurse remains with the child, watching for complications. The child's respiratory rate should be monitored. Be sure nothing is placed in the child's mouth during a seizure. Suction equipment should already be set up at the bedside before a seizure begins. The child should not be restrained during a seizure.
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A psychiatric nursing class is discussing current trends in mental health care
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