# A 28-year-old woman on the unit suddenly loses consciousness, becomes rigid throughout her body, and is observed to have rhythmic jerking of her arms and legs. Which action should the nurse take FIRST?

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> subject: Nursing

## 문제

A 28-year-old woman on the unit suddenly loses consciousness, becomes rigid throughout her body, and is observed to have rhythmic jerking of her arms and legs. Which action should the nurse take FIRST?

·Vital signs: BP 135/88 mmHg, pulse 108 beats/min, respirations 22 breaths/min, SpO2 95%
·Seizure duration: 2 minutes so far
·Client status: frothy secretions around the mouth, upward deviation of the eyes

## 보기

1. Notify the provider to obtain an order for lorazepam
2. Maintain a patent airway and administer oxygen **✔ 정답**
3. Establish IV access and prepare for laboratory studies
4. Hold the client's arms and legs to restrain the movements
5. Document the duration and characteristics of the seizure

**정답: 2**

## 해설

During a seizure, the priority nursing intervention follows the ABC (airway, breathing, circulation) principle: maintain a patent airway and provide oxygen. Because secretions around the mouth place the client at risk for airway obstruction, the airway must be secured immediately. Anticonvulsant administration is considered when a seizure lasts longer than 5 minutes or recurs without a return to consciousness; at 2 minutes, airway management takes priority over medication.

## 심화 해설

The top priority in seizure care is securing the airway and providing oxygen

When a seizure occurs, abnormal excessive neuronal activity in the brain temporarily disrupts consciousness, motor function, sensation, and autonomic function[1]. This client is demonstrating a generalized tonic-clonic seizure, in which a tonic phase of whole-body rigidity is followed sequentially by a clonic phase of rhythmic jerking of the extremities. During a seizure, the greatest risk is hypoxia resulting from biting the tongue during masseter spasm, or from airway obstruction caused by rigidity of the respiratory muscles and excessive secretions. The frothy secretions around the mouth and the upward deviation of the eyes are important clinical signs pointing to this risk of airway obstruction.

Nurses play a decisive role in recognizing and managing seizures, and this role includes airway management, hemodynamic monitoring, and safe administration of anticonvulsants[1]. However, all of these interventions are meaningful only on the premise that ventilation is maintained. Because the tongue can fall back or secretions can occlude the airway during a seizure, opening the airway and delivering oxygen first is the initial life-preserving step. At 2 minutes into the seizure, most seizures still have a good chance of stopping spontaneously within 5 minutes, but secondary brain injury from hypoxia must be prevented in the meantime.

Option 1, administering lorazepam, is a pharmacologic intervention to consider when the seizure progresses to status epilepticus, lasting longer than 5 minutes. Option 3, establishing IV access, is also needed for medication administration, but it is not the priority to rush toward while the airway remains unsecured. Option 4, holding down the extremities, must always be avoided because it can cause muscular or skeletal injury. Option 5, documenting seizure characteristics, is an important nursing responsibility to carry out after the seizure ends or once the airway and oxygenation have been addressed.

The essence of nursing care for a client having a seizure is "protect the airway and provide oxygen," and this is the emergency management principle emphasized as the highest priority even in high-fidelity simulation-based education[1].References (research sources)

- [1]Effectiveness of a high-fidelity simulation program based on flipped learning for nurses' emergency management of seizures: a mixed-methods design.Research articleJu JK, Choi O, Ahn S, Jeong HW. (2025) · DOI: 10.1186/s12912-025-03966-1

## 임상 시나리오

Emergency Nursing Guide for the Client Having a SeizureAirway and oxygenation come first
When a seizure occurs, securing the airway and providing oxygen are performed first. Airway obstruction from the tongue falling back or from secretions must be prevented in order to avoid hypoxia.

If the seizure lasts less than 5 minutes, it usually resolves spontaneously, so efforts focus on preventing secondary brain injury during that time. Lorazepam is considered for status epilepticus lasting longer than 5 minutes.

CautionHolding down the extremities of a client who is actively seizing must always be avoided, as it can cause muscle injury or fractures.

## 핵심 개념

- **Generalized tonic-clonic seizure** — A seizure type in which loss of consciousness and whole-body rigidity (tonic phase) are followed by rhythmic jerking of the extremities (clonic phase)
- **Status epilepticus** — An emergency in which a seizure lasts longer than 5 minutes or recurs without a return to consciousness; the high risk of brain injury requires immediate pharmacologic intervention
- **Hypoxia** — A state of inadequate oxygen in body tissues that can develop during a seizure from respiratory muscle rigidity or airway obstruction and can cause brain injury

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