A nurse is reinforcing teaching with a client who is planning to complete a living will. Which of the following statements by the client indicates an understanding of the teaching?

A. Oriented to person only indicates the client is confused about time, place, or situation, which increases the risk of injury due to impaired judgment and decreased awareness of surroundings. This cognitive impairment can lead to unsafe behaviors like attempting to get out of bed unassisted or wandering.

B. Hearing acuity intact helps the client receive verbal instructions and alarms, reducing injury risk by facilitating communication and timely responses to safety cues. Good hearing supports situational awareness, which is protective against accidents.

C. Ability to use call light allows the client to summon assistance when needed, helping prevent falls or other injuries. This functional independence in communication is a key safety factor in the acute care setting.

D. Full range of motion in bilateral lower extremities indicates good physical mobility and strength, which decreases injury risk by enabling the client to reposition safely and maintain balance during transfers or ambulation.

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• Place a tongue blade in the client’s mouth: This is unsafe and outdated.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.