A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following action should the nurse take?

Insert an oral airway into the client’s mouth

Measure the duration of the seizure.

Lower the side rails of the bed when the seizure begins.

Restrain the client's arms and legs to prevent injury.

Answer and Explanation

The Correct Answer is D

A. Insert an oral airway into the client’s mouth: Attempting to insert any object into the mouth during a seizure risks airway obstruction, dental injury, or aspiration of oral secretions or broken teeth. The jaw is typically clenched, making insertion unsafe and impractical.

B. Measure the duration of the seizure: While timing the seizure is important for documentation and determining if status epilepticus occurs, it should not take precedence over immediate physical safety measures. Restraint to prevent injury must occur first.

C. Lower the side rails of the bed when the seizure begins: Lowering the side rails increases the risk of the client falling from the bed. Instead, the bed rails should remain raised and padded (if possible) to create a contained, safe environment.

D. Restrain the client's arms and legs to prevent injury: Gentle but firm restraint of the extremities reduces the risk of the client striking themselves against hard surfaces (e.g., bed rails, walls) or experiencing dislocations, fractures, or self-inflicted trauma. Restraint should be applied cautiously to avoid excessive force, but it is necessary to maintain physical control during the seizure’s intense muscular contractions.

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Correct Answer is D

Explanation

A) Tonic-clonic seizures: Tonic-clonic seizures are typically the result of a seizure disorder, but during electroconvulsive therapy (ECT), a controlled seizure is intentionally induced to facilitate the therapeutic effects. After the procedure, there should not be uncontrolled tonic-clonic seizures. The goal is to induce a seizure under controlled conditions during the procedure itself, so this is not an expected finding 15 minutes post-ECT.

B) Paresthesias: Paresthesias (tingling or numbness) are not a common immediate side effect following ECT. While ECT can have some neurological effects, paresthesias are more commonly associated with other neurological conditions or nerve injuries, rather than as a direct result of the procedure itself.

C) Sleep apnea: Sleep apnea is not a typical immediate consequence of ECT. While ECT can have a range of physical and psychological side effects, sleep apnea, which involves breathing interruptions during sleep, is not an expected finding following the procedure.

D) Disorientation: Disorientation is a common and expected finding following ECT. It typically occurs due to the temporary effects of anesthesia, the brain’s response to the electrical stimulation, and the stress of the procedure. Clients often experience confusion, memory loss, and disorientation for a short period, particularly in the first 15 minutes after the procedure, as the anesthesia wears off and they recover from the induced seizure. This is a normal part of the recovery process.

A. I participate in physical activities 3 times per week B. I use sunscreen with an SPF of 10.* C. I limit playing video games to 3 hours per day." D. I have had sexual relations, but did not get the HPV vaccine."

Correct Answer is D

Explanation

A) I participate in physical activities 3 times per week: Engaging in physical activity is a positive behavior and is not considered high-risk. Regular physical activity is important for maintaining overall health and preventing obesity, cardiovascular disease, and other health issues.

B) I use sunscreen with an SPF of 10: While using sunscreen is a protective behavior, an SPF of 10 is lower than the recommended SPF of at least 30 for effective protection against harmful UV radiation. This is not the most significant high-risk behavior compared to others, but it still indicates some risk of sun damage.

C) I limit playing video games to 3 hours per day: Limiting screen time to 3 hours per day can be considered a balanced approach to video gaming. While excessive screen time can be problematic, 3 hours per day is not necessarily a high-risk behavior for an adolescent, as long as it doesn't interfere with other important aspects of life, like physical activity, sleep, and socialization.

D) I have had sexual relations, but did not get the HPV vaccine: Engaging in sexual activity without receiving the HPV vaccine is a high-risk behavior. The HPV vaccine helps prevent certain strains of the human papillomavirus, which can cause cervical cancer and other cancers. Lack of vaccination increases the risk of contracting HPV and developing related complications.

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A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following action should the nurse take?

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