A nurse is caring for a client.

Exhibits

Select the 4 findings that require immediate follow-up.

Rationale for Correct Choices:

• Turn the patient on their side: During a seizure, the first priority is to ensure the patient’s safety. Turning the client on their side helps prevent aspiration of saliva or vomit and keeps the airway clear, reducing the risk of choking or aspiration pneumonia.
• Loosen the client's gown: After ensuring safety and airway, the nurse should promote comfort and airflow by loosening restrictive clothing. This can help minimize risk of injury and ease breathing during or immediately after the seizure.

Rationale for Incorrect Choices:

• Note the time: While documenting the time of the seizure is important, the immediate action should focus on the patient’s airway and safety. After ensuring that the patient is safe, noting the time can be done to track the event for clinical purposes.
• Document the seizure event: Documentation is essential, but the first priority should be the safety of the patient. Once the patient is stable and their safety is ensured, documenting the seizure event can be done. This would follow airway management and patient safety.
• Reorienting the client: The immediate postictal period, the client may still be confused or disoriented due to the aftereffects of the seizure. The immediate priority should be airway management and comfort rather than reorientation, which can occur later.
• Administering anticonvulsant medications: If the seizure lasts for an extended period (over 5 minutes) or if seizures recur, anticonvulsant medications would be necessary. However, in this scenario, the seizure has already stopped. The first actions are to ensure airway safety, reposition the client, and provide comfort.

A. Assess the client every hr for circulation, possible injury, and readiness for discontinuation: While regular assessment is necessary, it should be done more frequently than every hour. A check every 15-30 minutes is recommended for safety.

B. Check the client's peripheral pulses and skin integrity every 15 min: Frequent assessments of circulation, skin integrity, and injury help prevent complications like tissue damage or nerve impairment.

C. Assist the client with passive range of motion exercises every 3 hr: Passive range of motion exercises should be done more frequently than every 3 hours to prevent stiffness and joint contractures.

D. Attach the extremity restraint straps to the bed rails using a quick-release buckle: Restraints should never be attached to bed rails, as this increases injury risk. Straps should be secured to a stationary part of the bed frame.