The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit.The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure.What is the best nursing action?
A) Assist the patient to the floor and provide soft head support.
B) Insert a nasogastric tube and connect to continuous wall suction.
C) Open the patient's mouth and insert a padded tongue blade.
D) Restrain the patient's extremities until the seizure subsides.

Question

Quizplus · Accepted Answer

To reduce the risk of further injury,a patient experiencing seizure activity while sitting in a chair should be assisted to the floor with head adequately supported.Routine insertion of a nasogastric tube during seizure activity is not indicated unless there is risk for aspiration.Forceful insertion of a padded tongue blade should not be carried out during tonic-clonic activity; most likely the patient's jaws will be clenched shut.Forceful insertion may lead to further injury.Restraining a patient during seizure activity can be traumatizing and is not standard of care.

The Nurse Responds to a High Heart Rate Alarm for a Patient