The nurse reviews the client's test results.

Exhibits

Complete the following sentence by using the list of options.

The nurse should

and

A. Insert an oral airway into the client's mouth.Inserting anything into the client’s mouth during a seizure is contraindicated due to the risk of oral injury, aspiration, or causing airway obstruction.

B. Lower the side rails of the bed when the seizure begins.Lowering the side rails is inappropriate and increases the risk of the client falling out of bed and sustaining an injury. Instead, the nurse should ensure padded side rails are in place or protect the client by cushioning their head and limbs if side rails are not padded.

C. Measure the duration of the seizure.It is critical to measure the duration of a seizure to provide accurate information to the healthcare team. The duration helps determine the severity of the seizure and the need for medical interventions, such as administering medications to stop prolonged seizures (status epilepticus).

D. Restrain the client's arms and legs to prevent injury.Restraint during a seizure is inappropriate and can cause musculoskeletal injuries. The nurse should allow the seizure to run its course while ensuring the client’s safety.

A. Incorrect. Limiting the client's social interactions would not be helpful and might further exacerbate feelings of dependence.
B. Correct. Encouraging the client to be assertive is an important aspect of promoting independence and self-advocacy. Clients with dependent personality disorder may struggle with asserting themselves, and fostering assertiveness can improve their overall well-being.
C. Incorrect. Assuming responsibility for making the client's decisions would reinforce their dependence, which is not the goal of treatment.
D. Incorrect. Maintaining a verbal, no-harm contract is typically used for clients at risk of self-harm or harm to others and is not directly related to addressing the challenges of dependent personality disorder.