A nurse in a provider's office is collecting data from an adult client. The client states that they are having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?

A. AP places a weight-sensitive sensor mat on the mattress beneath a client's buttocks.: This is a standard fall-prevention intervention and is not a hazard.

B. Client with a TENS unit reports a buzzing sensation.: This is a normal, expected sensation during TENS therapy.

C. Client with bilateral wrist restraints has a capillary refill of < 2 seconds.: This is a positive finding indicating that the restraints are not too tight and circulation is intact.

D. An assistive personnel raises all four side rails: Raising all four side rails is considered a restraint and is a major safety hazard, as it increases the risk of the client trying to climb over them and falling from a greater height.

Correct answers: At 1000 the nurse enters the client's room. The first action the nurse should take is call for assistance followed by turn the client to their side.

i. call for assistance: According to the nursing process, once a seizure begins (the ictal phase), the nurse must ensure they have help to manage the client's safety and monitor the event. The nurse should stay with the client but call for another staff member to bring emergency equipment or notify the provider.

ii. turn the client to their side: This is the priority safety intervention during a generalized tonic-clonic seizure. Turning the client to a lateral position helps maintain a patent airway and prevents aspiration of oral secretions or vomitus.

Rationale for incorrect answers:

remove the pillows: While removing pillows can help prevent airway occlusion if the head is hyper-flexed, calling for help and positioning the client on their side are higher priorities in the sequence of emergency management.

reorient the client: This occurs during the postictal phase (after the seizure has ended) when the client is regaining consciousness, not during the active seizure at 1000.

administer anticonvulsant medications: While medications like IV lorazepam may be indicated if a seizure is prolonged (status epilepticus), the immediate physical safety and airway management are the first nursing actions.