Medical Surgical Seizures #5

Question

The nurse is receiving a new admission from the emergency department with seizures. Which of the following actions will the nurse perform to institute seizure precautions? Select all that apply.

Answers

  1. Provide a visible airway at the bedside or connected to the headwall.
    • Rationale:

      This answer is correct because seizures can cause upper airway obstruction. Muscle contraction may cause the client to stop breathing. The client’s tongue may also obstruct the airway. Having supplies for airway management at the bedside is first priority.

  2. Place a padded tongue blade at the bedside or connected to the headwall.
    • Rationale:

      This answer is not correct because having anything in the client’s mouth may injure the client during a seizure. Also, it is unsafe for the nurse to place her hand inside the client’s mouth during a seizure. It is impossible for a client to swallow their tongue during a seizure.

  3. Ensure the bed is in a high position with a bedside sign to maintain position.
    • Rationale:

      This answer is not correct because of the risk of a fall during a seizure. A fall during a seizure can cause more serious problems. The bed should always be in the lowest position during a seizure. Some hospitals put mattresses on the floor to prevent fall injury.

  4. Ensure the bed is in a low position with a bedside sign to maintain position.
    • Rationale:

      This answer is correct because keeping the bed in the lowest position reduces the risk of a fall. Some hospitals put mattresses on the floor to prevent fall injury. Two of the major nursing priorities when a client has a seizure is airway management (first) and safety (second).

  5. Place pads around the inside of the hospital bed for protection.
    • Rationale:

      This answer is correct because the nurse should provide padding around the inside of the bed to prevent injury if the client has a seizure. Reducing self-harm is a priority for the client during the seizure.

Overview

A seizure is a sudden uncontrolled electrical discharge in the brain. Seizure precautions include padding side rails, preventing injury, monitoring airway, no restraints, turning the client on their side to prevent aspiration, and suction as needed.

Explanation

Learning Outcomes

Seizures are uncontrolled, sudden electrical impulses in the brain which make individuals do various things, depending on the cause. Client symptoms include changes in behavior, uncontrollable movements, and changes in level of consciousness. Seizure precautions include having airways available, and oxygen and suction equipment and supplies at bedside. Additionally, side rails may be padded and the bed is kept in the low position. Using a tongue blade whether padded or not may injure the client during a seizure and are not recommended. Two of the major nursing priorities when a client has a seizure is airway management (first) and safety (second).

Test Taking Tip

Two of the major nursing priorities when a client has a seizure is airway management (first) and safety (second). This reflects the consistent priority of ABCs (airway and breathing) and Maslow’s Hierarchy of Needs (breathing then safety)

Video Rationale