A nurse is collecting data from a female client who has a body mass index of 32. The nurse should classify the client as which of the following?

Rationale for Correct Answers:

• Turn the client to their side: This is a crucial first action. During a seizure, turning the client to their side (recovery position) helps to maintain an open airway, prevent aspiration of saliva or vomitus, and allow secretions to drain from the mouth.
• Call for assistance: After ensuring the client's safety and positioning, the nurse should call for help to ensure appropriate and prompt support from the healthcare team.

Rationale for Incorrect Answers:

• Restrain the client: Restraining a client during a seizure can cause injury. Instead, ensure the area is safe and the client is protected from harm without restricting movement.
• Place a tongue blade in the client’s mouth: This is unsafe and outdated. Inserting anything in the mouth during a seizure can break teeth or obstruct the airway.
• Administer lorazepam: Although lorazepam is used to treat ongoing prolonged seizures, it is not the first action in this scenario. Medication administration follows basic safety measures and calling for support.

A. Bear weight on the unaffected leg: In a three-point gait, the client bears weight only on the unaffected leg while advancing both crutches and the affected leg together. This gait pattern is used when one leg is non-weight-bearing or injured, ensuring safety and stability during ambulation.

B. Stand with the crutch tips against the feet: Crutch tips should be positioned about 6 inches to the side and slightly in front of the feet to provide a stable base of support. Placing crutches directly against the feet increases the risk of slipping and instability.

C. Hold the arms straight when walking: Arms should be slightly flexed at the elbows when holding crutches to absorb shock and reduce strain. Holding the arms straight can cause fatigue and reduce control during walking.

D. Keep the crutches at the level of the axillae: Crutches should be adjusted to about 1 to 2 inches (2.5 to 5 cm) below the axillae to prevent pressure on the nerves and blood vessels in the armpits, which could cause nerve damage or circulatory problems.