Neurological Question #13

Question

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

Answers

  1. Protect the client from injury.
    • Rationale:
  2. Place a padded tongue blade between the teeth.
    • Rationale:
  3. Lay the client in supine position immediately.
    • Rationale:
  4. Give oxygen by facemask immediately.
    • Rationale:

Overview

Explanation

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. Padded tongue blades are controversial and best practices indicate that they may break and splinter, causing more injury and should not be used. Lying supine is not correct as the client needs to be placed on the side in a recovery position to assist with airway and prevent aspiration of mucous or emesis. Oxygen may be given but may not be the priority over safety. Please note: in this question the word SAFETY is addressed. If the nurse insists that respiratory status IS safety, do not confuse it in the question as worded. In seizures, oxygen may not be the primary problem that the patient requires assistance with. SAFETY is vital.

Learning Outcomes

Test Taking Tip

Video Rationale