Which action would the nurse take for a client who is having a tonic-clonic seizure quizlet

What to Do When Someone Has a Seizure

Witnessing someone with epilepsy having a seizure can be truly frightening. But most seizures aren't an emergency. They stop on their own with no permanent ill effects.

There isn't much you can do to stop a seizure once it starts. But there are simple steps you can take to protect someone from harm during a seizure. It's worth knowing some basic first aid -- and when it's time to call 911.

Types of Seizures, Degrees of Danger

Some are more dangerous than others. There are two main types:

Focal onset seizures start in a single part of the brain. Their arm might start to move or their face start to twitch. And even though they're awake and aware, they can't control it. They might seem to zone out or stare at nothing as the seizure becomes complex. Afterward, they may not remember a thing.

Generalized seizures involve multiple areas of the brain at once. People are rarely aware of what's happening. The most well-known type falls in this group: the generalized tonic-clonic seizure, also known as a grand mal seizure. These are frightening to watch and can be an emergency.

They have a set sequence of events:

  • The person may become unresponsive. They don't answer if you call. They won't react if you wave a hand in their face or shake them. They may suddenly collapse.
  • Their muscles clench and they become rigid as a board. This is the tonic phase. It lasts a few seconds.
  • Next, a series of jerking movements convulse their body. This is the clonic phase. It can last a few seconds or several minutes.
  • Eventually, the jerking stops and they regain consciousness. They may be confused or disoriented for a short period.

Any generalized seizure can be dangerous because the person is unaware of their surroundings and can't protect themselves from harm. The uncontrolled thrashing movements during a generalized tonic-clonic seizure increase the chances of injury. This type is most likely to result in a trip to the emergency room.

First Aid

Seizure first aid is a matter of taking precautions. You're most likely to need it for a generalized tonic-clonic seizure.

  • Keep other people out of the way.
  • Clear hard or sharp objects away from the person.
  • Don't try to hold them down or stop the movements.
  • Place them on their side, to help keep their airway clear.
  • Look at your watch at the start of the seizure, to time its length.
  • Don't put anything in their mouth. Contrary to a popular myth, you can't swallow your tongue during a seizure. But if you put an object in their mouth, they could damage their teeth or bite you.

Milder seizures -- like brief periods of staring or shaking of the arms or legs -- aren't emergencies. But you should gently guide the person away from threats. They may be in a state like sleepwalking, where traffic or stairs pose a danger. All seizure activity should be reported to their doctor..

Call 911 if the person has difficulty breathing or waking after the seizure or if the seizure lasts longer than 5 minutes.

Capstone Med Surg Assessment

1.A nurse is teaching a client about using a continuous positive airway

pressure (CPAP) device to treat obstructive sleep apnea. Which of the

following information should the nurse include in the teaching?

It delivers a present amount of airway pressure throughout the breathing

cycle

2.A nurse is providing discharge teaching to a client following a heart

transplant. Which of the following information should the nurse include in

the teaching?

Shortness of breath might be an indication of transplant rejection

3.A nurse is caring for a client who has syndrome of inappropriate

antidiuretic hormone (SIADH) and is receiving 3 % sodium chloride via

continuous IV. Which of the following laboratory finding should the nurse

identify as an indication that the SIADH is resolving?

Urine specific gravity 1.020

4.A nurse is teaching a client about fecal occult blood testing (FOBT) for the

screening of colorectal cancer. Which of the following statements should

the nurse include in the teaching?

You should avoid taking corticosteroids prior to testing

5. A nurse is preparing a client for a colonoscopy. Which of the following

medications should the nurse anticipate the provider to prescribe as an

anesthetic for the procedure?

Propofol

6.A nurse is planning care for a client who has acute pancreatitis. Which of

the following interventions should the nurse include in the clients plan?

Select all that apply.

Monitor blood glucose levels

Maintain NPO status until pain-free

Manage acute pain

Which action would the nurse take for a client who is having a tonic

If you are with someone who has a tonic-clonic seizure: Do not put anything in their mouth. Turn them onto their side. Make sure the area around their body is clear of objects that could hurt them.

What to do if someone has a tonic

For someone having a generalized tonic-clonic seizure:.
Give them room. Keep other people back..
Clear hard or sharp objects, like glasses and furniture, away..
Cushion their head..
Loosen clothing around their neck, if you can safely..
Don't try to hold them down or stop their movements..

How would the nurse describe the clonic phase of a tonic

The tonic phase of a tonic-clonic seizure is described as stiffening of the body for several seconds. During the tonic phase, extraocular movements, apnea, and tongue biting may occur. This phase is also associated with activation of the sympathetic nervous system.

What nursing intervention should be provided for a client who is experiencing a seizure?

Maintain in lying position, flat surface; turn head to side during seizure activity; loosen clothing from neck or chest and abdominal areas; suction as needed; supervise supplemental oxygen or bag ventilation as needed postictally. Improve self-esteem.

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