ANCC Medical-Surgical Nursing Exam Prep

Answer - C - The first priority is to protect the client from injury. Do not restrain the client’s arms or legs, but make sure he or she does not hit anything. Protect the head with the nurse’s hand, a towel, or a jacket. During the initial tonic phase, the client usually stops breathing for up to minute. There is no cause for alarm, as spontaneous breathing will, in most clients, return with no harm. In the absence of breathing, airway patency by this position change (Choice B) is not the first priority. Muscle contraction will prevent “positioning” of the head. A padded tongue blade, once indicated during a seizure, is also no longer used. Choices A and D are appropriate nursing actions after the seizure has ended.