Difficulty: Medium
Average Score: 74%
Simulated
The client diagnosed with a brain abscess is experiencing a tonic-clonic seizure. Which interventions should the nurse implement? Rank in order of performance.
Correct answer
E,B,C,D,A
Rationale
1. Protect the clientÔÇÖs head (E): Prevents injury during convulsions. 2. Loosen restrictive clothing (B): Ensures airway and circulation. 3. Turn to the side (D): Prevents aspiration post-seizure. 4. Administer phenytoin (C): Stops the seizure after safety is ensured. 5. Assess the mouth (A): Done post-seizure to check for injury.