# A nurse is caring for a client who begins to have a generalized tonic-clonic seizure. Place the following nursing actions in the correct order.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=620069&lang=en  
> language: en  
> subject: Use of Restraints/Safety Devices  
> category: SIPC

## Question

A nurse is caring for a client who begins to have a generalized tonic-clonic seizure. Place the following nursing actions in the correct order.

Stay with the client and call for help.

Position the client on their side.

Document the seizure duration and characteristics.

Protect the client's head from injury.

Loosen restrictive clothing.

## Explanation

During a seizure, the nurse must first ensure safety by staying with the client and calling for help to activate the emergency response system. Next, protect the client's head from injury using a soft object. Then, loosen restrictive clothing to prevent injury and promote breathing. After that, position the client on their side to maintain a patent airway and prevent aspiration. Finally, after the seizure ends, document the seizure duration, characteristics, and client's response.

## In-depth explanation

Quick answer
During a seizure, the nurse must first ensure safety by staying with the client and calling for help to activate the emergency response system. Next, protect the client's head from injury using a soft object. Then, loosen restrictive clothing to prevent injury and promote breathing. After that, position the client on their side to maintain a patent airway and prevent aspiration. Finally, after the seizure ends, document the seizure duration, characteristics, and client's response.
Key cues
Use only the findings and timing stated in the scenario.
Clinical reasoning
Match each response to the immediate nursing decision and the client condition.
Why the alternatives do not fit
The remaining responses are mistimed, incomplete, outside the requested scope, or contradicted by the scenario.
Priority and safety
Address immediate threats and use reassessment to confirm the response.
Takeaway
Apply the sequence or grouped decisions exactly as the scenario requires.
**Sources**
- Open RN Nursing Skills 2e

## Clinical scenario

A nurse is caring for a client who begins to have a generalized tonic-clonic seizure. Place the following nursing actions in the correct order.

## Key concepts

- **generalized tonic-clonic seizure** — generalized tonic-clonic seizure is a key clinical concept for assessing and managing active seizure bedside response.
- **airway management** — airway management is a key clinical concept for assessing and managing active seizure bedside response.
- **seizure precautions** — seizure precautions is a key clinical concept for assessing and managing active seizure bedside response.

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