# A nurse is caring for an adult client with epilepsy who suddenly has a generalized tonic-clonic seizure on the inpatient unit. Which actions should the nurse take during the seizure and the immediate postictal period? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=366782&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A nurse is caring for an adult client with epilepsy who suddenly has a generalized tonic-clonic seizure on the inpatient unit. Which actions should the nurse take during the seizure and the immediate postictal period? Select all that apply.

1

Insert a padded tongue blade or oral airway between the client's teeth during the convulsion to prevent tongue biting

2

Activate the emergency response if the seizure reaches 5 minutes or recurs before consciousness returns

3

Physically restrain the client's arms and legs to stop the convulsions and prevent injury

4

Stay with the client, time the seizure, lower the client safely if standing, and protect the head with a pad

5

After convulsions end, position the client side-lying to drain secretions and maintain the airway

6

Loosen tight neck clothing, remove sharp or hard objects, and pad the head and bed rails

## Explanation

Stay with the client, time the seizure, lower the client safely if needed, and protect the head (Choice 4). Loosen tight clothing, clear nearby hazards, and use padding to reduce injury (Choice 6). After the convulsive phase ends, place the client side-lying to support secretion drainage and airway patency (Choice 5). A seizure lasting 5 minutes or recurrent seizures without recovery requires emergency response because it meets the operational threshold for status epilepticus (Choice 2). Do not place an object in the mouth because it can injure the teeth or obstruct the airway (Choice 1). Do not restrain the limbs because restraint can cause musculoskeletal injury (Choice 3).

## In-depth explanation

Seizure Safety — During the Seizure
1. Stay and time the seizure (call for help)
2. Ease to floor if standing; protect the head with padding
3. Clear the area of hazards, loosen tight clothing
4. Nothing in the mouth — no tongue blade, no fingers
5. Do not restrain — let convulsions complete
6. Apply oxygen if available; suction PRN

Post-Ictal Period
- Side-lying (recovery) position for airway and secretion drainage
- Suction as needed
- Reorient gently — confusion, fatigue, headache common
- Allow rest; document characteristics (onset, duration, body parts involved, autonomic signs, post-ictal state)
- Assess for tongue laceration, falls injury, incontinence

Status Epilepticus
Seizure > 5 min OR repeated without recovery = neurologic emergency. IV lorazepam (or diazepam, midazolam) first-line. Notify provider STAT, prepare airway, IV access, glucose check.

Memory Tip
"SAFE": Stay & time, Airway side-lying after, Free of hazards, End-of-seizure documentation.

## Clinical scenario

Scenario
Adult, history of epilepsy, on levetiracetam. Suddenly begins generalized tonic-clonic seizure while ambulating in the hallway. Falls to the floor, full convulsions begin.

Immediate Action (During)
1. Call for help
2. Time the seizure from onset
3. Protect head with pillow or hands
4. Move objects away, loosen collar
5. Do NOT insert anything in mouth
6. Do NOT restrain

After Seizure (Post-Ictal)
- Side-lying recovery position
- Suction secretions, oxygen PRN
- Vital signs, neuro check, fingerstick glucose
- Reorient gently, do not give food or fluids until fully awake
- Document: time, duration, characteristics, post-ictal duration, injuries

When to Escalate
- Seizure > 5 min or repeated → STATUS EPILEPTICUS — IV benzodiazepine, 911 if outpatient
- New focal neurological deficit (Todd paralysis vs stroke)
- Injury (head, tongue, fall)
- Aspiration suspected

## Key concepts

- **Generalized tonic-clonic seizure** — Bilateral seizure with loss of consciousness, tonic phase (rigid muscle contraction, often with cry, apnea), then clonic phase (rhythmic jerking). Typically lasts 1-3 minutes. Followed by post-ictal period with confusion, fatigue, headache, sometimes Todd's paralysis (transient focal weakness). > 5 min = status epilepticus.
- **Status epilepticus** — Continuous seizure activity > 5 minutes OR repeated seizures without recovery of consciousness between them. Neurologic emergency due to risk of permanent neuronal damage and aspiration. First-line treatment: IV lorazepam 2-4 mg (or IM/intranasal midazolam, rectal diazepam if no IV). Maintain airway, oxygen, fingerstick glucose, IV access.
- **Post-ictal nursing care** — Recovery period after a seizure. Place client side-lying to protect airway and allow secretion drainage; assess and maintain ABCs; monitor vital signs and neurologic status; reorient gently as confusion is common; assess for injuries; do not offer food or fluids until fully awake. Document characteristics of the seizure thoroughly.

## Related questions

- [A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=en)
- [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=en)
- [A 72-year-old client is brought to the emergency department by family who report that the …](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=en)
- [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=en)
- [A 68-year-old client is admitted to the emergency department with suspected sepsis from a …](https://mymerci.kr/pages/nclex_q.php?qn_id=363987&lang=en)
- [A nurse is caring for an adult client in the emergency department who is suspected to have…](https://mymerci.kr/pages/nclex_q.php?qn_id=363993&lang=en)
- [A nurse is teaching a 72-year-old client with chronic heart failure (reduced ejection frac…](https://mymerci.kr/pages/nclex_q.php?qn_id=366202&lang=en)
- [A nurse is caring for an adult client admitted with diabetic ketoacidosis. Laboratory resu…](https://mymerci.kr/pages/nclex_q.php?qn_id=366294&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=366782&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=366782&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=366782&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=366782&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=366782&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._