A nurse is caring for a client who has limited mobility in their lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

A. "I am ready to learn about chemotherapy to help cure my cancer.": This statement indicates that the client is focused on curative treatment rather than comfort-oriented care. Introducing palliative care at this stage may not align with the client’s current goals and could cause confusion or distress, as palliative care emphasizes quality of life rather than curing the disease.

B. "I just want you to give me something to get this over with soon.": This statement may reflect fear, despair, or a desire to hasten death. While it signals emotional distress, it does not indicate readiness to discuss palliative care. The nurse would first need to assess for psychological support, clarify the client’s wishes, and ensure safety before initiating a palliative care conversation.

C. "I know that many people have recovered fully from cancer, and so will I.": The client demonstrates a strong focus on recovery and hope for a cure. This indicates that they are not yet receptive to discussions about end-of-life care or palliative interventions, as their attention is directed toward disease eradication rather than symptom management.

D. "I want you to tell me about measures available to keep me comfortable.": This statement directly reflects the client’s interest in comfort, symptom relief, and quality of life. It demonstrates readiness to receive information about palliative care interventions, such as pain management, emotional support, and end-of-life planning, making it the most appropriate cue for the nurse to proceed with palliative care education.

Rationale for correct choices

• Physical safety: During an active seizure, the immediate priority is protecting the client from injury. The nurse must ensure the environment is safe by removing nearby objects, lowering the client to the floor if necessary, and preventing head trauma. Attempting to control other aspects before ensuring safety can place the client at risk for fractures, head injury, or aspiration. Protecting the client from harm is always the first priority in seizure management.

• Positioning: After ensuring the client’s safety, positioning the client is essential to maintain airway patency and prevent aspiration. Placing the client on their side allows secretions or vomitus to drain from the mouth and helps keep the airway clear. Proper positioning also reduces the risk of aspiration pneumonia. Maintaining airway protection is the next critical step following environmental safety.

Rationale for incorrect choices

• Blood pressure: Monitoring blood pressure is important in overall assessment, but it is not the immediate priority during active seizure activity. The primary concerns are airway protection and prevention of injury. Vital signs can be assessed after the seizure subsides and the client is stabilized. Addressing blood pressure before safety and airway management would delay critical interventions.

• Privacy: Maintaining privacy is important for dignity and comfort but is not the immediate concern during a medical emergency such as an active seizure. Life-preserving interventions must take priority over privacy considerations. Immediate action focuses on preventing injury and maintaining airway.

• PRN medication: Lorazepam may be administered to control seizure activity, particularly if the seizure is prolonged. However, medication administration follows initial safety and airway interventions. Attempting to administer medication before ensuring the client is protected from injury and properly positioned may compromise safety. Stabilization and positioning occur first.

• Incontinence: Loss of bladder or bowel control can occur during seizures, but managing incontinence is not a priority during the event. The nurse should address hygiene and comfort after the seizure has ended and the client is stable. Immediate care focuses on safety, airway, and seizure control rather than cleanup.