Medical Surgical Seizures #6

Question

A client is having a grand mal seizure. Which of these interventions by the nurse will ensure safety during the seizure?

Answers

  1. Protect the client from injury.
    • Rationale:

      This answer is correct because it is important to maintain safety by providing protection from injury during a grand mal seizure. Depending on where the seizure occurs, the first action is to provide a safe area and clear the environment of any item that may cause injury. In this question the word SAFETY is addressed. Placing the client in the recovery position is safe practice. Take the client’s arm nearest you and place it at a right angle with the hand pointing in an upwards position. Place their opposite hand on the floor against their cheek and support their head while they are on their side and raise their chin to facilitate opening of their airway. Keep legs bent slightly.

  2. Place a padded tongue blade between the teeth.
    • Rationale:

      This answer is not correct because padded tongue blades are controversial and best practices indicate that they may break and splinter, causing more injury and should not be used. Nothing should be placed into a client’s mouth while seizuring, as this is a choking hazard. Remember a client cannot choke on their own tongue.

  3. Lay the client in supine position immediately.
    • Rationale:

      This answer is not correct because lying supine during a seizure places the client at risk for aspiration of mucus or emesis. The client needs to be placed on the side in a recovery position to assist with a patent airway.

  4. Give oxygen by facemask immediately.
    • Rationale:

      This answer is not correct because while oxygen is definitely important and may be given, it is not the priority over safety. If the nurse insists that respiratory status IS safety, do not confuse it in the question as worded.

Overview

Grand mal seizures are also known as tonic-clonic seizures. Grand mal seizures are intense seizures that involve a loss of consciousness and extreme muscle contractions, and afterwards, a postictal period. First priority is to stay with the client to ensure safety.

Explanation

Learning Outcomes

Grand mal seizures are violent and can potentially cause injury to the client. The most important thing to remember with seizures is to maintain safety and protect the client from injury. Placing clients in the recovery position and monitoring their airway are two of the most important interventions. These interventions can help prevent aspiration and prevent injury. Other interventions include padding the side rails of the bed and placing the bed in the lowest position. It is important not to restrain a seizing client. Place suction materials at the bedside. Remember to observe the length of the seizure and afterwards to document the time it started and the time it ended and what happened during the seizure.

Test Taking Tip

Utilize Maslow’s Hierarchy of Needs prioritization to consider the safety risks associated with seizures. Noticing the word “safety” is addressed in this sentence will help students answer this question, since safety is vital.

Video Rationale