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1. Question
The nurse is caring for the client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated?
Correct
Answer & Rationale:
Option 2 is Correct
Rationale: Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed.
Incorrect
Answer & Rationale:
Option 2 is Correct
Rationale: Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed.
What is Seizures ?
A seizure is the physical findings or changes in behavior that occur after an episode of abnormal electrical activity in the brain.
The term “seizure” is often used interchangeably with “convulsion.” Convulsions occur when a person’s body shakes rapidly and uncontrollably. During convulsions, the person’s muscles contract and relax repeatedly. There are many different types of seizures. Some have mild symptoms without shaking.
Symptoms
Seizures of all types are caused by disorganized and sudden electrical activity in the brain.
Causes of seizures can include:
Abnormal levels of sodium or glucose in the blood
Brain infection, including meningitis
Brain injury that occurs to the baby during labor or childbirth
Brain problems that occur before birth (congenital brain defects)
Brain tumor (rare)
Drug abuse
Electric shock
Epilepsy
Fever (particularly in young children)
Head injury
Heart disease
Heat illness (heat intolerance)
High fever
Phenylketonuria (PKU), which can cause seizures in infants
Poisoning
Street drugs, such as angel dust (PCP), cocaine, amphetamines
Stroke
Toxemia of pregnancy
Toxin buildup in the body due to liver or kidney failure
Very high blood pressure (malignant hypertension)
Venomous bites and stings (snake bite)
Withdrawal from alcohol or certain medicines after using for a long time
