A nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic-clonic seizure. Which of the following interventions should the nurse take?

Insert a padded tongue blade into the client's mouth.

Place a pillow under the client's head.

Gently restrain the client's extremities.

Keep the client in a supine position.

Answer and Explanation

The Correct Answer is B

A. Insert a padded tongue blade into the client's mouth.

This intervention is not recommended. Placing any object, including a padded tongue blade, into the mouth of someone experiencing a seizure poses a risk of injury, such as biting the tongue or breaking teeth. It can also obstruct the airway and increase the risk of aspiration. Therefore, inserting anything into the client's mouth during a seizure is contraindicated.

B. Place a pillow under the client's head.

Placing a pillow under the client's head can help prevent head injury by providing cushioning and support. It can also help maintain the client's airway and reduce the risk of aspiration. Therefore, this intervention is appropriate and helps ensure the client's safety during the seizure.

C. Gently restrain the client's extremities.

Restraining the client's extremities is not recommended during a seizure. It can increase the risk of injury, such as fractures or dislocations, and may exacerbate muscle contractions. It's important to allow the client's movements to occur naturally while taking measures to ensure their safety, such as removing nearby objects and providing a safe environment.

D. Keep the client in a supine position.

It is essential to ensure that the client's head is turned to the side (recovery position) to prevent aspiration and allow for drainage of oral secretions. Additionally, the nurse should remove any nearby objects that could pose a risk of injury during the seizure.

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Correct Answer is C

Explanation

A. Aura phase:

The aura phase occurs before the seizure and is characterized by subjective sensations or experiences that some individuals may have. It serves as a warning sign that a seizure is about to occur. This phase precedes the seizure itself and is not applicable to the period immediately afterward.

B. Presence of automatisms:

Automatisms refer to repetitive, involuntary movements or actions that some individuals may exhibit during certain types of seizures, such as complex partial seizures. They are not typically observed during the postictal phase of a generalized tonic-clonic seizure.

C. Postictal phase:

The postictal phase, also known as the postictal state, refers to the period following a seizure during which the individual may experience confusion, drowsiness, or other altered states of consciousness. This phase typically lasts for minutes to hours and is characterized by gradual recovery of normal function.

D. Presence of absence seizures:

Absence seizures are characterized by brief episodes of altered consciousness, often manifesting as staring spells or momentary loss of awareness. They are distinct from generalized tonic-clonic seizures and do not involve the same postictal phase characterized by drowsiness and altered arousal.

A. Monitor for elevated blood pressure. B. Provide analgesia for headaches. C. Prevent bladder distention. D. Elevate the client's head.

Correct Answer is C

Explanation

A.While monitoring for elevated blood pressure is important in identifying autonomic dysreflexia once it occurs, it does not prevent the condition. The nurse should focus on eliminating potential triggers, such as bladder distention or constipation, to prevent the occurrence.

B.Headaches are a symptom of autonomic dysreflexia, often related to severe hypertension. While treating the headache may alleviate discomfort, it does not address the underlying cause, nor does it prevent the onset of autonomic dysreflexia.

C.Bladder distention is a common trigger for autonomic dysreflexia in individuals with spinal cord injuries. The nurse should ensure that the client's bladder is regularly emptied to prevent overdistention, which can stimulate the autonomic reflex and trigger AD.

D.Elevating the head is an intervention used during an episode of autonomic dysreflexia to help lower blood pressure and reduce symptoms. However, this action does not prevent the condition from occurring.

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