A nurse is caring for a patient experiencing a tonic-clonic seizure. Which nursing intervention should be the priority during the seizure activity?
1Insert a padded tongue blade between the patient's teeth to prevent tongue biting
2Restrain the patient's extremities to prevent injury from violent movements
3Position the patient on their side and protect the head from injury✓ 정답
4Administer oxygen via nasal cannula at 4 L/min immediately
해설
During a tonic-clonic seizure, the priority is to maintain airway patency and prevent injury by positioning the patient on their side and protecting the head. Other options, such as inserting objects or restraining, can cause harm and are contraindicated.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention during the acute phase of a Tonic-clonic seizure (Generalized seizure). The core principle is Safety First. During a seizure, the nurse's primary role is to protect the patient from harm while maintaining a patent airway, as the patient is unconscious and cannot protect themselves. The interventions must be simple, safe, and evidence-based.
Answer Rationale: Key Point! The correct answer is Position the patient on their side and protect the head from injury. This single action addresses the two most critical needs during a seizure: Airway management and Injury prevention. Positioning on the side (the recovery position) allows secretions to drain from the mouth, preventing aspiration. Protecting the head (e.g., with a pillow or your hands) prevents traumatic injury. This is the universal, immediate priority.
Distractor Analysis:
Watch out for confusion! Option 1: Insert a padded tongue blade... is absolutely contraindicated. Forcing an object into the mouth can cause dental damage, oral lacerations, or even airway obstruction if the object breaks. The tongue cannot be "swallowed" during a seizure.
Option 2: Restrain the patient's extremities... is also contraindicated. Restraint can lead to fractures, dislocations, or soft tissue injuries due to the powerful, involuntary muscle contractions. It can also increase agitation.
Option 4: Administer oxygen via nasal cannula immediately is a secondary intervention, not the priority during the active seizure. Attempting to place a nasal cannula on a convulsing patient is impractical and could cause injury. Oxygen administration is typically initiated after the seizure has ceased to treat postictal hypoxia.
Related Concepts: The nursing care for seizures follows a clear sequence: During the seizure (ictal phase): Protect (side-lying, head protection), Time the seizure, Loosen restrictive clothing. After the seizure (postictal phase): Maintain side-lying position, Assess airway/breathing/vital signs, Provide oxygen, Reorient the patient, and allow for rest. Document the event in detail.Nursing Clinical Practice GuideClinical Scenario: You are on a medical-surgical unit. Your patient, Mr. Johnson, diagnosed with epilepsy, suddenly loses consciousness, lets out a cry, and his body becomes rigid (tonic phase), followed by rhythmic jerking of all extremities (clonic phase).
Nursing Intervention Strategy:
Immediate Action (Safety & Airway): Stay calm. Call for help if needed. Gently guide the patient to the floor if in bed (lower side rails first). Place a pillow or folded blanket under the head. Log-roll the patient onto their side. Loosen any tight clothing around the neck.
Assessment & Timing: Note the time the seizure started. Observe and mentally document the sequence of events (e.g., "started with head turning to the right, then generalized tonic-clonic activity").
Post-Seizure Care: After movements stop, the patient will enter the postictal phase (confused, drowsy). Keep them on their side. Check breathing and pulse. Administer oxygen via non-rebreather mask if ordered or per protocol. Perform a neurological assessment (Glasgow Coma Scale (GCS)). Reorient gently as they awaken.
Documentation: Document everything: time of onset/end, characteristics, patient's condition before/after, interventions performed, and patient response.
Patient Safety and Precautions: Never force anything into the mouth. Do not restrain. Do not attempt to give oral medications or fluids during or immediately after the seizure. If the seizure lasts longer than 5 minutes, or if a second seizure begins without the patient regaining consciousness (Status epilepticus), this is a medical emergency requiring immediate intervention (e.g., IV benzodiazepines like lorazepam).
Nursing Procedure & Medication FlowSeizure Precautions: For at-risk patients, ensure the bed is in the lowest position with side rails up (padded if necessary). Keep suction equipment and oxygen at the bedside.
Emergency Medication (for Status Epilepticus):
First-line: IV Lorazepam or Diazepam. Administer slowly as per order to stop seizure activity.
Monitoring: Watch for respiratory depression and hypotension, which are major side effects of benzodiazepines. Have bag-valve-mask (BVM) ready.
A Word from Your Senior Nurse
"In the chaos of a seizure, your calm, purposeful actions are everything. Remember: 'Protect, Position, and Time.' Your priority is not to stop the seizure (you can't), but to keep the patient safe while it runs its course. The instinct to 'do something' like putting something in the mouth is strong but wrong. Trust your training. Your documentation is also a critical nursing intervention—it provides essential data for the healthcare team to adjust the treatment plan. On the NCLEX, they love to test these 'do no harm' priorities!"
Tonic-Clonic Seizure — A type of generalized seizure characterized by two phases: a tonic phase (muscle stiffening, loss of consciousness) followed by a clonic phase (rhythmic jerking of muscles).
Postictal Phase — The period of recovery following a seizure, where the patient may be confused, drowsy, fatigued, or have a headache. Neurological function gradually returns to baseline.
Status Epilepticus — A medical emergency defined as a seizure lasting more than 5 minutes or recurrent seizures without regaining consciousness between them. Requires immediate intervention to prevent brain damage.
Airway Patency — The state of having an open, unobstructed airway, which is the first priority (the "A" in ABCs) in any emergency situation, including during and after a seizure.
Recovery Position — Placing an unconscious but breathing patient on their side with the lower arm in front of the body. This position helps maintain an open airway and allows fluids to drain, preventing aspiration.