The nurse observes an ambulating client begin to experience a tonic-clonic seizure. Which nursing actions should be implemented immediately? Select all that apply. A)Guide the client to the floor and gently cradle the head B)Insert a tongue blade to prevent client from swallowing the tongue C)Move objects that may cause injury away from the client D)Physically restrain the client to prevent injury E)Place the client in left lateral position F)Remain with the client, observe, and record the seizure activity

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11ecbb05_cb48_5ad6_b433_3786b07eb83e_MD0009_00 Protecting the ambulating client from injury is the immediate priority. The nurse assists the client to the floor, cradles the head, and places the client in the left lateral position. Left lateral position is preferred to avoid the risk of aspiration. Hard or sharp objects should be removed from the client's environment to prevent injury. The nurse remains with the client until the seizure is over to assess seizure activity and postictal symptoms and to minimize injury. (Option B) No objects should be placed in a client's mouth during a seizure. Following the seizure, the client may require assessment and maintenance of the airway, suctioning, and oxygen administration. (Option D) Attempting to restrain a client during a seizure may cause injury to the client. Educational objective: Safety measures implemented during a seizure include positioning the client to protect from injury, maintaining a patent airway, and observing the seizure activity. During the seizure, the nurse does not restrain the client or place objects in the client's mouth.

The Nurse Observes an Ambulating Client Begin to Experience a Tonic-Clonic